Oral lesions in patients with psoriasis: clinical presentation and management

Concurrent chronic hyperplastic candidosis and oral lichenoid lesion as adverse events of secukinumab therapy

Secukinumab (Cosentyx®) is an IL-17A inhibitor which is used for the management of psoriasis, active psoriatic arthritis or ankylosing spondylitis. Oral adverse events of secukinumab therapy are not widely appreciated. This article highlights the presentation of two concurrent oral adverse events of secukinumab therapy; namely chronic hyperplastic candidosis (CHC) and oral lichenoid lesion (OLL). This is the first documented case report of CHC occurring as a consequence of secukinumab therapy, and represents a new adverse effect which general and specialist oral health practitioners should be aware of. This case highlights the importance of correlating the presence of oral lesions with the patient's medical history, keeping up to date with the development of new medications and pharmacotherapeutics, having a deep understanding of underlying biological processes related to various oral diseases, and appreciating the use of clinical adjunctive devices. Accurate diagnosis is key to formulating a correct management plan.

Oral mucosal lesions in psoriatic patients based on disease severity and treatment approach

BACKGROUND

This observational case-control study was designed to investigate the frequency of oral lesions in psoriatic patients and to identify an association between mucosal involvement, the severity of the disease, and a form of treatment.

METHODS

One hundred twenty-seven patients diagnosed with psoriasis were enrolled in this study from November 2018 to September 2019. The oral mucosa evaluation was based on the clinical appearance, location, and morphology of the lesions. All patients completed a general medical history and a Dermatology Life Quality Index (DLQI) questionnaire. The severity of skin involvement was assessed using the Psoriasis Area and Severity Index (PASI) scale.

RESULTS

The most common oral lesions in patients with psoriasis were found to be fissured (FT), white coated (CT), and geographic tongue (GT). A significantly lower prevalence of GT was evident in the group managed with a new class of biological drugs and smokers. There appeared to be no association between the oral manifestation and the PASI score. FT appeared significantly more often in patients that experienced an extremely large effect of psoriasis on their quality of life as determined by the DLQI questionnaire and smokers. Only 25% of patients presented normal oral mucosa.

CONCLUSIONS

Tongue lesions seem to be associated with skin psoriasis regardless of the treatment. The severity of the disease, according to the PASI scale, does not influence mucosal involvement. The type of treatment may affect the prevalence of oral lesions. Further investigations are required to confirm the influence of biological therapies on mucosal improvement.

Oral Psoriasis of the Tongue: A Case Report

Psoriasis is a common dermatological disease, but oral psoriasis is rarely reported in the literature. Its diagnosis has been a contentious issue among physicians. Its presence in the absence of skin lesions is not completely accepted by all physicians, and diagnosis is complicated by the fact that there are no defined criteria. We present a case report of oral psoriasis in a man who did not have skin lesions concurrently but did have a previous history of dermal psoriasis. Additionally, we discuss the history, typical presentation, and current treatments of oral psoriasis.

A Rare Case of Intraoral Psoriasis

Psoriasis is a chronic inflammatory mucocutaneous disease predominantly affecting the skin. While oral manifestations are common in many papulosquamous conditions, the occurrence of oral lesions in psoriasis is relatively rare. This case report highlights the presence of oral lesions in cutaneous psoriasis and the need for early identification of such lesions for timely management and better symptomatic improvement.

Tongue psoriasis: Clinical aspects and analysis of epidemiological associations in 313 children, with a systematic literature review

BACKGROUND

Little information is available on the prevalence and clinical aspects of tongue involvement in children with psoriasis. The aim was to evaluate the prevalence, clinical aspects and risk factors concerning tongue involvement in children with psoriasis.

PATIENTS AND METHODS

This study was carried out in two stages. We performed a multicentre, cross-sectional study in 23 French dermatology centers. All children seen for psoriasis during the one-year study were systematically included. The clinical features of the tongue and of psoriasis were recorded. Association with clinical aspects of psoriasis and comorbidities was evaluated. We then carried out a literature review to evaluate the prevalence of tongue involvement in children with psoriasis and its positive predictive value for psoriasis. A search was conducted in the PUBMED database using the following keywords: "child" and "psoriasis" and ("tongue" or "glossitis" or "migratory glossitis" or "benign migratory glossitis" or "geographic tongue" or "fissured tongue").

RESULTS

7.7% of the 313 children with psoriasis had tongue involvement. The clinical aspects were geographic tongue (4.2%), fissured tongue (2.8%) and both (0.64%). There was no association between tongue involvement and the clinical characteristics of the children. Two hundred and ninety-five articles were referenced and 3 were analysed. Psoriasis is very rare in cases of tongue abnormalities.

CONCLUSION

The prevalence of tongue involvement was 7.7% in children with psoriasis. No clinical or epidemiological association was shown. Tongue involvement does not modify the management of psoriasis. In the literature review it was not possible to evaluate either the prevalence of tongue involvement in psoriasis or the positive predictive value thereof.

Oral Manifestation in Patients diagnosed with Dermatological Diseases

AIM

This study aimed to estimate the frequency of oral lesions in dermatological diseased patients attending the outpatient department of Pravara Rural Medical and Dental College and Hospital, Pravara Institute of Medical Sciences (Deemed University), Loni, Ahmednagar, Maharashtra, India, and the Department of Dermatology at Medical College, Ahmednagar, Maharashtra, India.

MATERIALS AND METHODS

A cross-sectional hospital-based study was conducted in Loni from October 2013 to January 2014. A total of 310 patients (mean age 37.2 ± 16 years, 61.2% males) completed an oral examination and a personal interview. Oral lesions were recorded. Biopsy and smear were used as adjuvant techniques for confirmation. Data were analyzed using Statistical Package for the Social Sciences (SPSS) (version 15.0.1).

RESULTS

Of 310 cases (n = 310) observed for skin lesions, 99 cases were psoriasis (31.93%) and 68 cases were lichen planus (LP; 21.9%), followed by herpes zoster in 44 cases (14.1%), herpes simplex in 13 cases (4.1%), pemphigus vulgaris (PV) in 15 cases (4.8%), erythema multiforme (EM) in 8 cases (2.5%), bullous pemphigoid (BP) in 4 cases (1.2%), chicken pox in 3 cases (0.9%), eczema in 52 cases (16.7%), and nutritional deficiency and candidiasis in 2 cases (Table 1).

CONCLUSION

The dermatologic diseases studied frequently occur in the oral cavity. Among them, psoriasis was the most common dermatological disease, and LP frequently showed.

CLINICAL SIGNIFICANCE

This study also depicts that diagnosis and management of these oral lesions should also be carried out by oral clinicians so as to improve the oral health functioning during the course of the disease. The intraoral examination should be incorporated to the routine of dermatologic assistance as the oral manifestations can represent preliminary signs or can coexist with the diseases.

Oral Psoriasis: An Overlooked Enigma

Although cutaneous psoriasis is common, the existence of its manifestations in the oral cavity has been questioned. The definitive diagnosis of oral psoriasis can be challenging due to the variability of presentations, and overlapping clinical and histological features with a number of other conditions as well as the lack of consensus. We review oral psoriasis, noting its variable clinical appearance, delineate the differential diagnosis, and discuss management strategies.

Oral psoriasis-a diagnostic dilemma: a report of two cases and a review of the literature

Whether psoriasis can manifest itself in the oral mucosa has been a matter of debate for many years. If an oral version of psoriasis exists, most researchers regard this manifestation as rare. The present report describes two patients who presented with lesions possibly related to cutaneous psoriasis. One patient had patchy erythematous lesions on the gingiva, and one had serpiginous lesions in the hard palate. We discuss these cases in relation to the existing literature, with special emphasis on the clinical and histopathologic criteria for the diagnosis of oral psoriasis.

Association of chronic periodontitis and psoriasis: periodontal status with severity of psoriasis

OBJECTIVES

The chronic periodontitis (CP) and psoriasis share common risk factors and co-morbidities. This study was designed to explore how frequently CP is associated with patients with psoriasis compared to systemic healthy subjects.

MATERIALS AND METHODS

The periodontal clinical parameters probing depth (PD), periodontal attachment level (PAL), and presence or absence of radiographic bone loss (J Periodontol, 78, 2007, 1387) were recorded in 33 psoriasis subjects and 35 healthy subjects. The severity of psoriasis was assessed and recorded by Psoriasis Area and Severity Index as described earlier by Cohen et al (J Dermatolog Treat, 16, 2005, 308). The other oral health characteristics were also recorded.

RESULTS

Probing depth and PAL showed significant higher values in psoriasis group compared with healthy group. It was also found that periodontal status was associated with severity of psoriasis.

CONCLUSIONS

The results showed a link between CP and psoriasis. This suggests the need for a multidisciplinary approach to manage psoriasis patients with chronic periodontitis, especially in relation to current and future treatment.

Clinical Aspects of the Oral Cavity in Patients with Psoriasis: An Initial Study and a Proposal of a New Evaluation Method

The involvement of the oral cavity is rare but possible in patients with psoriasis. Most frequently different clinical entities are reported such as geographic tongue, fissures, angular cheilitis and ectopic geographic tongue. This interdisciplinary study was conducted by dermatologists in collaboration with dental hygienists on 22 patients with psoriasis. We examined 11 men and 11 women aged between 25 and 72 years during a period of 6 months. The involvement of the oral cavity was examined and a full photographic evaluation was carried out. A new assessment evaluation named Oral Psoriasis Area and Severity Index (OPASI) is proposed herein. The results obtained show the presence of oral lesions in 45.6% of the cases. This high involvement could be explained by the interdisciplinary nature of the study. We believe OPASI can be useful to assess the severity of lesions of the oral cavity, and may help to evaluate the response to therapy in relation to the Psoriasis Area and Severity Index (PASI) improvement.

[Oral lesions in psoriasis]

BACKGROUND

The literature contains little information about the incidence or prevalence of oral signs in psoriasis. The pustular forms are the most commonly incriminated, with geographic tongue being the most frequently cited oral sign. The aim of our study was to determine the various types of oral signs seen in a large population of psoriasis patients.

PATIENTS AND METHODS

Four hundred psoriasis patients were recruited consecutively and a detailed oral examination performed by two clinicians. Similar examinations were performed over the same period in 1000 nonpsoriasis subjects comprising a control group in order to assess the incidence of the same oral signs in the general population.

RESULTS

Comparing the two groups, fissured tongue was seen in 33.2% of psoriasis patients versus 9.9% of control subjects (P<0.0001). There was thus a highly significant (P<0.0001) correlation between geographic tongue and psoriasis (7.7% of psoriasis patients versus 1% of controls). In addition, a strong correlation was seen between the presence of pustular psoriasis and fissured tongue (83.3% of patients with pustular psoriasis versus only 30% of patients with other forms of psoriasis).

DISCUSSION

Our study shows a strong correlation between psoriasis and fissured and geographic tongue, although these features are not pathognomonic for the disease. As regards geographic tongue, our results are consistent with the data in the literature. However, the prevalence of fissured tongue was considerably higher among our patients than in series published to date. These two types of sign involving the tongue, and which can occur in all forms of psoriasis, appear to be particularly strongly associated with pustular psoriasis. Patients are generally unaware of this sign and rarely complain of it.

Periodontitis in psoriasis patients: a blinded, case-controlled study

OBJECTIVE

Destructive periodontitis is one of the most frequent and widespread bacterial infections in humans. Psoriasis is a common condition in the general population. Since both psoriasis and periodontal diseases are characterized by an exaggerated response of the immune system to the epithelial surface microbiota, there may possibly be an association between these two conditions. The aim of the present pilot study was to investigate the prevalence of periodontal disease in psoriasis patients compared to healthy controls.

MATERIAL AND METHODS

Dental bite-wing X-rays were obtained from 155 psoriasis patients aged 45-60 years, as well as from 155 age- and gender-matched controls. All X-rays were examined by the same investigator for accumulated destructive periodontitis using bone level and loss of teeth as endpoints.

RESULTS

A significantly lower radiographic bone level (p < 0.001) and a significantly higher number of missing teeth (p < 0.001) were observed in the psoriasis cases compared to the controls.

CONCLUSION

Our study indicates that psoriasis patients experience more bone loss than age- and gender-matched controls.

Tongue lesions in psoriasis: a controlled study

BACKGROUND

Our objective was to study tongue lesions and their significance in psoriatic patients.

METHODS

The oral mucosa was examined in 200 psoriatic patients presenting to Razi Hospital in Tehran, Iran, and 200 matched controls.

RESULTS

Fissured tongue (FT) and benign migratory glossitis (BMG) were the two most frequent findings. FT was seen more frequently in psoriatic patients (n = 66, 33%) than the control group (n = 19, 9.5%) [odds ratio (OR): 4.69; 95% confidence interval (CI): 2.61-8.52] (p-value < 0.0001). BMG, too, was significantly more frequent in psoriatic patients (28 cases, 14%) than the control group (12 cases, 6%) (OR: 2.55; 95% CI: 1.20-5.50) (p-value < 0.012). In 11 patients (5.5%), FT and BMG coexisted. FT was more frequent in pustular psoriasis (7 cases, 53.8%) than erythemato-squamous types (56 cases, 30.4%). On the other hand, the frequency of BMG increased with the severity of psoriasis in plaque-type psoriasis assessed by psoriasis area and severity index (PASI) score.

CONCLUSIONS

Nonspecific tongue lesions are frequently observed in psoriasis. Further studies are recommended to substantiate the clinical significance of these seemingly nonspecific findings in suspected psoriatic cases.

Oral psoriasis in an 11-year-old child: a case report

Psoriasis is a chronic inflammatory dermatosis that very rarely involves the oral mucosa. There is no consistent pattern of clinical presentation in the oral cavity. Furthermore, manifestations of intraoral psoriasis in paediatric patients are extremely rare and only one case appeared to have been reported in the literature to date. In this paper we report a case of intraoral psoriasis in an 11-year-old child who had been previously diagnosed as having dermal psoriasis.

Position Paper: Oral Features of Mucocutaneous Disorders

Part of periodontology involves the diagnosis and treatment of a variety of non-plaque-related diseases of the periodontium. The International Workshop for a Classification of Periodontal Diseases and Conditions noted that the periodontist may be called upon to manage non-plaque-related mucocutaneous disorders either alone, or as part of a treatment team consisting of physicians, dentists or other allied health care professionals. This informational paper will review the etiology, clinical manifestations, diagnosis, and treatment of the most common chronic mucocutaneous diseases, including those that may present as desquamative gingivitis or intraoral vesiculobullous lesions. This paper is intended for the use of periodontists and other members of the dental profession.

Oral psoriasis

It is strange that the existence of oral psoriasis seems so rare. Other papulosquamous disorders, such as lichen planus, are frequently associated with oral manifestations, yet oral psoriasis is rare given the prevalence of cutaneous disease. One explanation is that oral lesions are asymptomatic and do not come to the clinician's attention. Other explanations, however, are necessary. Epithelial turnover time is significantly increased in psoriatic plaques and may be as rapid as 3 to 7 days, whereas normal epithelial turnover is 28 days. Some have suggested that this abnormally increased turnover time in psoriasis approximates that of the normal regenerative time of the oral epithelium, and this possibility may account for the apparent lack of changes in the oral mucosa of patients with psoriasis [1]. It is also possible that oral lesions of psoriasis are altered both clinically and histologically by other factors within the oral microenvironment and are not recogized. Although controversy has appeared in the literature about whether lesions of oral psoriasis exist, there is sufficient evidence that a subset of patients have oral lesions in association with skin disease. This occurrence is more common in patients with the severe forms of psoriasis, such as generalized pustular psoriasis. The diagnosis of oral psoriasis should be based on good clinical and histologic evidence, and, in general, the clinical course of the oral lesions should parallel that of the skin disease. Exclusion of other causes is important, particularly if cutaneous lesions are absent and a diagnosis of isolated oral psoriasis is entertained. Because neither the clinical nor the histologic changes are absolutely specific for psoriasis, the patient requires holistic evaluation. That being said, in day-to-day practice it is most likely not practical to obtain a biopsy of asymptomatic oral lesions for definitive histologic or immunofluorescence studies. The clinician, however, must have a high degree of awareness and pay close attention to the oral mucosa in patients with psoriasis. A thorough examination is imperative, because asymptomatic oral lesions may be found more frequently in patients with psoriasis if clinicians habitually check mucous membranes during the generalized skin examination. Conversely, in patients with troublesome oral lesions, a cutaneous examination that reveals subtle changes suggestive of psoriasis may provide clues to the oral diagnosis. A detailed history remains the cornerstone of diagnosis, because a family history of psoriasis or a history of psoriasis now in remission may guide physicians when they note oral lesions.