Nutritional aspects of Dermatology (Skin and Food – is there a link?)

Matthew Strack Dermatologist Marinoto Clinic Dunedin Matthew Strack - Dermatologist

 GP registrar year 1989

 Fellow Royal Australasian College of Physicians  International Fellow American Academy of Dermatology Conflicts

 Have given talks and accepted travel grants from:  Roche - Roaccutane  Novartis - Cyclosporin  Sell Cetaphil cleanser at my office

• Eat Good things • Avoid Bad things Influences on Diet

 Performance  Culture  Social Interaction  Addiction  Cost  Availability  Technology  Habit Outline

 Food and Dermatology  Sugar  Dairy  Gluten  Nightshades

 Vitamin D

 Adverse Drug Reactions  Aspirin  Thiazides  Statins (x2)  Topical Steroids  Biologics Sugar/Fructose

 “Venous Eczema”  Acanthosis Nigricans  Psoriasis Mr M G

 Family Trip to Disneyland  Swelling in both legs  Clot rulled out  10 months Mr M G - Food

 breakfast - apricots, honey puffs, toast margarine, honey, coffee with milk  morning tea - coffee with milk lunch - sandwiches with honey, coffee with milk  dinner - various - meat with plenty of veges, ice cream, apple crumble, coffee with milk  supper - some biscuits

Insulin

“Empty Gut Calories Fructose Bacteria ”

Leptin Mr M G - Follow Up

 Has lost 10kg  Skin 90% clear  Occasional use of topical steroid Things are not what they seem

 F,30’s  Ref:dermatitis axillae Difficulty Washing Neck

 Hyperinsulinaemia Acanthosis Nigricans

 Diet – try sugar free ACCORD Study Accord 2

 Randomized multicentre study  N=10,251  Type 2 Diabeties  38% F, 35% previous cardiovascular event  Average age 62y  Glycated Hb at entry 8.1% (65 mmol/mol)  2 arms: Standard 7-7.9% (53-63 mmol/mol) Intensive < 6% (42 mmol/mol) Accord 3 Accord - Rate of death 4

 5.0% Intensive group  4.0% Standard group  P= .02 Mr RC – Insulin 1

 50y M  Police officer – physically active  Medicines: diltiazem, bendrofluazide, betaloc, vit d, simvistatin, allopurinol  Weight 112kg, BMI 29  Palmar Psoriasis  Methotrexate  Potent topical Steroid Mr RC – Insulin 2

 Fasting Glucose 5.0 mmol/L (n3.5-6.0)  Fasting Insulin 116 pmol/L (n10-80)  Offered low sugar diet Mr RC – Insulin 3 16 month follow up

 Weight 112kg -> 103kg  BMI 29 -> 26.7  Fasting Glucose 5.9 -> 5.6mmol/L (n3.5-6.0)  Fasting Insulin 116 -> 80 pmol/L (n10-80)  Reduced need for topical treatment  Palmar psoriasis improved Mr RC – Insulin 4

 Remains on 1 of 4 antihypertensive meds  Dose of remaining antihypertensive reduced  BP 145/95 pre diet -> 130/70  Improved exercise tolerance  was starting to wheeze with walking Effect of Weight Loss on the Severity of PsoriasisA Randomized Clinical Study Peter Jensen, MD, et al JAMA Dermatol. 2013;149(7):795-801. doi:10.1001/jamadermatol.2013.722 Adipocytes

 More than just fat storage cells  Release a rance of inflammatory chemicals

 Psoriasis is a chronic inflammatory systemic disease  Cardiovascular risk is increased in chronic inflammation  Severe disease is associated with increased risk of cardiovascular death Adam and Eve', by Lucas Cranach the Elder, 1526 “Half of what you learn at this medical school will be proved to be wrong. The trouble is that we do not know which half. “

Opening Lecture, first day at Otago medical school 1982

Emeritus Professor John Hunter (1925-2003) Dairy

 Acne Acne

Hyperkeratization Sebum Production Colonization Acne

 Possibly a corruption of “acme”  Acme = latin for a point or high spot Miley Cyrus Admits She's 'Struggled With Depression,'

Miley Cyrus is opening up about getting through a dark period in her life in Elle magazine . …

"It was a lot to do with, like, I had really bad skin, and I felt really bullied because of that.”  Journal of the American Academy of Dermatology 2005

Effect was stronger for low fat dairy products.

Acne and Dairy

 Several studies now confirm a positive link  Males show trend more strongly than females  Low Fat/Skim Milk shows strongest association  Positive association with BMI  Negative association with fish Kativan Islanders

 Population 2250  Subsistence horticulture and fishermen  1990 all homes visited  1200 subjects over age 10y  Included 300 aged 15-25

 Cordain et al, Archives of Dermatology, 138,Dec 2002, 1584-1590

Kativan Islanders

 Normal weight  No hypertension  Low Insulin  Low leptin  No Acne Acne – Case SW 1

 23 y f  3 courses isotretinoin in past  Doses ranging from 5-40mg  Currently on 4th course – has been on for 1 year,  acne not settling  Seen by two dermatologists Acne – Case SW 2

 Otherwise healthy  Normal build/BMI  Medication: Combined Oral Contraceptive  Nursing Student

 Options? Acne – SW 3

 Offered Gluten Free Dairy Free diet  Six month follow up:  Skin clear  Has reduced sugar intake as well  Off Isotretinoin  Placed on 1y review Acne - Conclusions

 Increasing in post adolescent patients  Recent studies show a role for diet change  Worse with dairy  Better with fish and unprocessed food

 Severe cases need medical treatment Treat Acne / Save the World?

Source:Melnik ADV 2013 Gluten

• Celiac Disease – Dermatitis Herpetiformis  Eczema  Lupus  Rosacea Ground Zero

 61y Male  Eruption natal cleft also elbows - settles with do - vesicles noted ? herpetic  Meds: simvistatin, quinapril, aspirin, citalopram, metformin, gliclazide  nonsmoker  wt 109kg - stable Blood Tests

 anti TTG IgA: *** > 150 units (0 - 20)  Endomysial Ab: *** POSITIVE  Comment:

 These results support a diagnosis of coeliac disease Clinical and Biopsy IgG autoimmunity Follow Up

 Small bowel biopsy  Strict Gluten Free diet  Review with dietician  Even stricter gluten free diet  Lost 6kg in 3/12 and 10cm around abdomen  No visible skin lesions, no therapy required for skin Fasano Scientific American 2009 Family History

 1st Degree Relative 1:22  2nd Degree Relative 1:39  Symptoms 1:56  Not at risk 1:133

Prevalence of celiac disease in at-risk and not-at-risk groups in the United States: a large multicenter study. Allesio Fasano: Archives of Medicine 2003

Norman Borlaug

 1914-2009  Father of the Green Revolution  Nobel Peace Prize 1970  Dwarf Wheat Celiac disease and Skin disease

 Alopecia areata  Aphthous stomatitis  Atopic dermatitis / Eczema  Cutaneous vasculitis  Dermatomyositis  Dermatitis herpetiformis  Oral lichen planus  Prurigo nodularis  Psoriasis  Urticaria  Vitiligo Eczema

 Female, 30’s  Lifelong Atopic Eczema  Worse since shifting from Scotland 3y ago  Cyclosporin – no help  Methotrexate Helped but stopped prior to pregnancy  Patch testing – neg  HLA DQ -pos  TTG - normal  40% erythema during pregnancy  Using topical Steroids  Striae  Azathioprine started post partum  Monitoring Bloods normal  Gluten free diet suggested Progress

 Significant improvement in eczema  Breast fed child’s eczema also cleared on gluten free diet!  Further improvement in patient/mother with elimination of rolled oats  Azathioprine dose halved and then stopped Eczema Before and after Eczema, unresponsive to topical steroids.

 65y F referred by GP  “Intensely itchy”  Dermatologist 14y ago:  Punch biopsy “inconclusive”  Meds: thyroxine, hrt, omeprazole  O/e – 25 x 15 cm right pretibial  Lichen simplex  Thickening Consultation

 “I have an intolerance to bread and scones”  Bloating Follow up

Able to stop omeprazole Lupus

 Systemic  Cutaneous  ANA+  Often negative  Immune complex  Cell mediated  Skin sometimes  Always Skin  Systemic Joints Internal  Can have SLE as well organs  Antimalarial effect  Weak/moderate  Strong Lupus

 58y F  ANA neg  2 biopsies confirm Lupus  Ttg 3 (0-20)  Sb 2 dermatologists  Gliadin IgG: 25 units  Resistant to topical, and (n<70) antimalarial  Gliadin IgA: 5 units  Works in science (n<15)  F hx nil of note  HLA DQ 2.2 and 2.5 pos  Vegetarian / Piscatarian Lupus RA/Lupus

 42y F TF  GP: Psoriatic Arthritis/Sjogrens  Rheumatology “RA/Lupus Cross”  2-4/12 lesions on toes  leflunomide, diclofenac, omeprazole RA/Lupus RA/Lupus

 Skin much better but not fully settled  Could not take zinc  Eating more on GF diet  Has been able to stop omeprazole Psoriasis 43y m

 Smokes 20/day  Meds: Salbutimol Inhaler  15% e2/3 s2/3 t2/3  Includes face and genital areas  Flare with URTI  Disease on elbows 10y Psoriasis 43y m

 Strep Serology negative  HLA DQ – 8 positive  Anti TTG IgA 16 (n 0-20)

 Topical Steroid  Penicillin  Acetretin  Gluten Free diet Psoriasis 43y m Odds ratio of increased IgG anti-gliadin Diet and psoriasis, part II: Celiac disease and role of a gluten-free diet Bhavnit K. Bhatia et al JAAD 2013 Rosacea 65y M

 GF  Lost 15kg 90->75kg  No minocycline last 3/12  Added Zinc last 3/12 Rosacea Rosacea

 Breakfast Toast, Muesli, lite margarine, coffee  Morning Tea Coffee with Apple  Lunch Soup with toast  Afternoon tea Biscuit and coffee  Dinner Chips, meat, packet gravy and veges  No desert/supper  Known Egg Allergy Before and after #1 Before and after #2 “Mostly Gluten Free”

 Breakfast – muesli  Lunch – Sandwich  Dinner – Pasta “a lot”  Snacks – includes cakes and biscuits Dietary Questionnaire:

 Breakfast  Morning Tea  Lunch  Afternoon Tea  Dinner  Supper  Snacks Case to Discuss

 F 30’s  Well educated health professional  Sarcoidosis with hand arthralgia  Hashimotos Thyroiditis – carbimazole  Acne – starting to settle with topical rx  Low fe Case to Discuss

 Hand arthralgia – cleared  Thyroid  Bloods normal  Carbimazole halved  Acne  Further improvement  Fe – normal Case to discuss - Radioiodine

 Should She have it? History

 Family History  Celiac  Wheat Allergy  Gluten Intolerance Family History

 22y M, ref “bothersome dermatitis”  Several courses of prednisone for skin  Pentaza for Crohn’s disease  F Hx: Grandfather, uncle, cousin – celiac  Results:  TTG 1 (n0-20)  HLA DQ 2.5  Skin almost clear  Prednisone not needed  Pentaza not restarted  Feels better in self

 Now on 2 topical steroids and 6 monthly review Tests

 Gluten Gene Tests: HLA DQ 2.2, 2.5, 8  TTG n=0-20  (Anti Gliadin IgG n=0-70)  (Deamidaded Gliadin Peptide)

 ?ANA  Unexplained Low Fe Gluten Free – Dr Strack's Way Summary of Patient Handout

 Commit to a strict 2 month trial  If you don’t want to do it, don’t do it!  Don’t eat too many “Gluten Free” Food Fresh Food: Meat, vegetables and fruit Eat fat, including Saturated fat – see next slide  Avoid Vegetable oils – exception: Olive Oil  Avoid Rolled Oats Meta-analysis of prospective cohort studies evaluating the association of saturated fat with cardiovascular disease. Siri-Tarine et al, Am J Clin Nutr 2009.27725 Things Change: 1984-2014 Have You Seen this? Nicotine Nightshade (Solanaceae) Family:

 Tobacco  Potatoes  Tomatoes  Eggplant  Peppers (bell peppers, chili peppers, paprika, tamales, tomatillos, pimentos, cayenne, etc)  Goji Berries Deadly Nightshade / Belladonna Nightshade Alkaloids  Steroid mimics  Muscle tremors – cholinesterase inhibitors  Only partlt removed with cooking  Tobacco – Nicotine  Potato, Tomato - Solanine  Deadly Nightshade – Scopolamine - Atropine Mr D S - Presentation

 48y male  Health care professional  Referred for skin check – past history includes nonmelanoma skin cancer  F hx 1 daughter with celiac disease  No current medications but for last 5y has developed generalized arthritis over winter each year Mr D S - Arthritis

 Rheumatologist – psoriatic arthritis  Has had steroid injections in ankles several times  Recently offered methotrexate by Rheumatologist  Skin check shows no skin cancers  Also lesions on arms that could be psoriasis Mr D S - Investigation

 Gene positive for Gluten sensitivity  Strongly positive anti-Gliadin antibody Mr D S - Follow up

 Seen 9/12 later  No arthritis this winter  No ankle swelling  Has not needed steroid injections in ankles  More energy Vitamin D – Controversy

Low vitamin D levels associated with increased risk of melanoma, thicker melanomas, higher relapse rates and reduced survival. Newton Bishop et al., 2009, Gambichler et al, 2012, Gandini 2013.

High vitamin D levels associated with increased risk of NMSC and melanoma. Jolieke et al., 2013,Eide et al., 2011, Asgari et al.,2010. Vitamin D The Skin is an Endocrine Organ Vitamin D – is the Sun Friendly?

 <10% from diet  Most efficient midday  UVB strongest midday  No lower threshold for UVB and skin cancer

 Recommendations? Dermatology Patients

 Melanoma  Multiple Skin Cancers  Immunosuppressive Drugs Drug Reactions Rash on Neck and Chest Aspirin

 inhibition of TXA2-dependent platelet aggregation  Blood half life 20min  Platelet life 10 days  Platelet recovery 10% per day ? Venous Eczema 2y + leisons arms and legs.

 Referred by gp  66y M  Irritating  Cryotherapy – no response  Interests  Gardening  Bowls – x3/week  Meds  Vit D  Ranitidne  Atorvastatin  Bezalip  Metoprolol  Aspirin Presentation Follow Up Follow Up Very Dry Skin

 74y M  Lifelong dry skin – much worse last 6/12  Mother and brother also dry skin  Statin Stopped  Suggested two eggs for breakfast

Is the use of cholesterol in mortality risk algorithms in clinical guidelines valid? Ten years prospective data from the Norwegian HUNT 2 study

52,000 Norwegiens aged 20-74 Petursson H et al, Journal of Evaluation in Clinical Practice 18 (2012) 159–168 Topical Steroids

 Acne  Unwanted Hair  Skin Thinning  Stretch marks  Red facial veins  Allergy (!) Using Topical Steroids

 Teenagers – Care!  Sensitive areas – Care!  Advise Quantity  Arrange Follow up

 Low Risk areas  Hands, Feet  Back Biologic Therapy Conclusion

 Find what is important  Find points of resonance  Hand outs can help here  Be prepared to be surprised  Get partners/family on board  Accept self abusers

Levels of Intervention

Junk Food

Sugar

Gluten

Carbohydrates Share Positive Emotions

 I am very pleased with your progress and I think you are doing very well.  This is great!  It has been a pleasure to treat you.  This has made my day! Take Home Points

 Skin Disease may a marker of deeper problems caused by food  Changes in diet can improve skin disease  Use a diet questionnaire  Family History – ask about:  Celiac  Gluten intolerance  Enlist Support from family – but don’t undermine  Be Nice! We are all different