Dermatology Online Journal

Psoriasis and oral lesions: Multicentric study of oral mucosa diseases italian group (GIPMO)
L Germi MD¹, V De Giorgi MD², F Bergamo MD³, M C Niccoli MD⁴, F Kokelj MD⁵, M Simonacci MD⁶, R A Satriano MD⁷, L Priano MD⁸, C Massone MD⁹, P Pigatto MD¹⁰, G Filosa MD¹¹, A De Bitonto MD¹², C Veller Fornasa MD¹
Dermatology Online Journal 18 (1): 11

1. Dermatology Unit, San Bortolo Hospital, Vicenza, Italy
2. Department of Dermatology, University of Florence, Italy
3. II Dermatology Division, IDI-IRCCS, Rome, Italy
4. Dermatology Unit, “Misericordia e Dolce” Hospital, Prato, Italy
5. Dermatological Clinic, University of Trieste, Trieste, Italy
6 Dermatological Unit, Macerata Hospital, Macerata, Italy
7. Department of Dermatology and Venereology, Second University of Naples, Faculty of Medicine, Naples, Italy
8. Division of Dermatology, E O Ospedali Galliera, Genoa, Italy
9. Department of Dermatology and Venerology, Division of General Dermatology, Medizinische, Universität, Graz, Austria
10. Department of Dermatology, University of Milan, IRCCS R. Galeazzi Hospital, Milan, Italy
11. Dermatological Unit, Jesi Hospital, Jesi, Italy
12. Dermatology Unit, Policlinico San Marco, Istituti Ospedalieri Bergamaschi, Zingonia, Bergamo, Italy

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Abstract

OBJECTIVE: This is a multicentric, observational and controlled study designed to verify the existence of a significant association between plaque-type psoriasis and oral lesions, such as geographic tongue and/or fissured tongue. STUDY DESIGN: during a period of 9 months all consecutive patients with plaque-type psoriasis were enrolled using simple nonrandom (sequential) sampling. The control group included healthy subjects presenting to the same Dermatology centers to monitor pigmented skin lesions; the patients were matched for age and sex. All patients were examined for oral lesions. RESULTS: Out of a total of 535 psoriatic patients and 436 control group patients, oral mucosal lesions were detected in 188 (35.1%) and 86 (19.7%) cases, respectively, and the difference is statistically significant. Fissured tongue (FT) and geographic tongue (GT), which were most frequently detected, were seen more frequently in psoriatic patients (FT: 22.6%; GT: 9.1%) than the control group (FT: 10.3%; GT: 5.2%) (p<0.05). CONCLUSIONS: On the basis of the similar studies reported in the literature and the large number of patients involved in our study, we can conclude that FT and GT can be clearly suggested as oral manifestations of plaque-type psoriasis, although the reason for this association is not clear.

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Introduction

The presence of specific oral manifestations in psoriasis has been questioned and has been a subject of controversy. Nowadays, there is sufficient evidence that a subset of patients have oral lesions in association with this skin disease. In particular, fissured tongue (FT) and geographic tongue (GT) are seen to occur with greater prevalence in patients with psoriasis than in healthy control patients. Although these show a statistical correlation with skin psoriasis, they usually are seen in otherwise healthy people in the general population, leading to an underestimation of the value of these findings in psoriatic patients [1-4].

On the basis of the absence of consistent literature regarding the association between psoriasis and oral lesions, twelve members of the Oral Mucosa Diseases Italian Group (GIPMO), that is composed of several Italian dermatologic centers, have organized a multicentric, observational, and controlled study of psoriasis and oral lesions to verify the prevalence of different oral mucosal lesions in patients with a confirmed diagnosis of psoriasis.

Methods

For 9 months 535 consecutive patients affected by plaque-type psoriasis (the most frequent variant of psoriasis observed), presenting spontaneously to the Dermatology clinics involved in this study, were enrolled using simple nonrandom (sequential) sampling, without distinction of disease severity. The previous studies have demonstrated the absence of significant association between the severity of psoriasis and the frequency of FT, the most frequent lesion found in psoriatic patients [2, 4, 5]. The psoriatic group was composed of 240 women (44.9%) and 295 men (55.1%) and the mean age of this group was 49.8 years (±16.1) (range 18 to 88 years). The mean duration of the disease was 9.9 years (±12.7) (range 6 months to 69 years).

The control group was composed of 436 healthy patients, matched for age and sex. These were patients visiting the Dermatology clinics for pigmented lesion assessment and monitoring. They were without any other significant skin disease. This group was composed of 185 women (42.4%) and 251 men (57.6%), with a mean age of 47.9 years (±17.9) (range 18 to 82 years).

All patients are examined for oral lesions including geographic tongue (GT) and fissured tongue (FT). These oral diagnoses were made clinically.

A questionnaire was completed for each patient to compare the presence and the frequency of oral lesions in a psoriatic population with respect to gender, age, and the following systemic diseases: hypertension, dyslipidemia, diabetes, atopy, Crohn disease, and chronic hepatitis.

Results

Data, analyzed using χ-square test, elaborated logistic models, and the odds ratio (OR) with a 95 percent confidence interval (CI) and p-value, exhibit a statistically significant difference between the number of oral lesions in the psoriasis group (188 - 35.1%) as compared with that of the control group (86 - 19.7%) (test χ², 1gdl=32; v-index: 18; p-value=0.001).

Fissured tongue (FT) and geographic tongue (GT) were the lesions detected in the majority of psoriatic and control patients. Fissured tongue (FT) was seen more frequently in psoriatic patients (121 patients, 22.6%) than the control group (45 patients, 10.3%) (p<0.01).

Also geographic tongue (GT) was found more frequently in the psoriatic group in our study (9.1%). Its prevalence, although lower in both groups, was statistically significant in the psoriatic patients (p=0.032).

Additional investigations revealed that the prevalence of FT and GT is not related to sex in both groups (p>0.05). FT showed a positive correlation with patient’s age (OR=1.35, 95%, IC=1.04-1.75, p-value=0.025). This correlation is not seen in the control group.

On the other hand, only GT showed a statistically significant association with the duration of psoriasis (p<0.05).

Regarding the systemic diseases detected by history, a significant association was found between psoriasis and dyslipidemia (p<0.01), hypertension (p<0.05), and diabetes (p<0.05), in accordance with the recent literature [5]. This association could explain the trend for FT to occur more frequently in individuals with hypertension (p<0.01) in both groups and with dyslipidemia in only the psoriatic group (p<0.01). On the other hand GT is associated with atopy (p<0.01) in the two groups and with diabetes only in the control group (p<0.01), but these systemic diseases are not significant variables in the logistic regression model for FT and GT in association with psoriasis.

Other oral lesions were observed less frequently and included papillar hypertrophy, aphthous stomatitis, and oral candidiasis. These were apparently not associated with psoriasis; there was no significant difference in the prevalence of these particular oral lesions among the two groups (p>0.05).

In the study group 236 patients (44.5%) were being treated with systemic therapy for psoriasis. There was no significant difference between the frequencies of FT and GT with regard to patients being treated or not (p>0.05).

Conclusions

In the literature, FT is the most common oral finding in the psoriasis group compared to GT or other oral lesions. FT has been reported in 6 percent to 47 percent of psoriatic patients by different authors. Costa [3] showed the presence of FT in 34.3 percent of the 166 patients with psoriasis and GT in 18 percent. Perez [2] reported FT in 47 percent and GT in 12.5 percent of 80 psoriatic patients. In the same way, Daneshpazhooh [1] (200 patients) and Tomb [4] (400 patients) observed that FT (33%) was more frequent than GT (respectively 14% and 7.7%). These findings are similar to our study in which we detected a greater frequency of FT than GT, 22.6 percent and 9.1 percent, respectively. However, the association with psoriasis is statistically significant for both lesions.

On the basis of the similar studies reported in the literature and the large number of patients enrolled in our study, we can conclude that FT and GT can be clearly suggested as oral manifestations of plaque-type psoriasis, although the reason for this association is not clear. It is possible that the patients with psoriasis share a susceptibility to these conditions.

AKNOWLEDGMENTS: The authors would like to thank Dr SSA Marisa Pacchin MD, Director of Epidemiology Department, ULSS 6 Vicenza City Hospital, and her assistent Dr Luca Sartori, degree in Statistics, for their kind assistance and their advice in data analysis and statistical evaluations.

References

1. Daneshpazhooh M, Moslehi H, Etesami MA e M. Tongue lesions in psoriasis: a controlled study. BMC Dermatol 2004 Nov 4; 4(1):16. [PubMed]

2. Pérez FH, Aveldañez AJ, Urquizo Ruvalcaba MLU, Díaz Barcelot M, Irigoyen Camacho ME, Vega Memije ME, Mosqueda Taylor A. Prevalence of oral lesions in patients with psoriasis. Med Oral Patol Oral Cir Bucal 2008 Nov 1;13(11):E703-8. [PubMed]

3. Costa SC, Hirota K, Takahashi MDF, Andrade H Jr , Migliari DA. Oral lesions in 166 patients with cutaneous psoriasis: A controlled study. Med Oral Patol Oral Cir Bucal 2009 Aug 1;14(8):e371-5. [PubMed]

4. Tomb R, Hajj H, Nehme E. Oral lesions in psoriasis. Ann Dermatol Venereol 2010 Nov;137(11):695-702. [PubMed]

5. Farley E, Menter A. Psoriasis: Comorbidities and associations. G Ital Dermatol Venereol 2011 Feb;146(1):9-15. [PubMed]

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