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

Matthew Strack

Dermatologist

Marinoto Clinic

Dunedin

GP registrar year 1989

Fellow Royal Australasian College of Physicians

International Fellow American Academy of Dermatology

Matthew Strack - Dermatologist

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

Performance

Culture

Social Interaction

Addiction

Cost

Availability

Technology

Habit

Influences on Diet

Food and Dermatology Sugar Dairy Gluten Nightshades

Vitamin D

Adverse Drug Reactions Aspirin Thiazides Statins (x2) Topical Steroids Biologics

Outline

“Venous Eczema”

Acanthosis Nigricans

Psoriasis

Sugar/Fructose

Family Trip to Disneyland

Swelling in both legs

Clot rulled out

10 months

Mr M G

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

Mr M G - Food

Fructose

Insulin

Gut

Bacteria

Leptin

“Empty

Calories”

Has lost 10kg

Skin 90% clear

Occasional use of topical steroid

Mr M G - Follow Up

F,30’s

Ref:dermatitis axillae

Things are not what they seem

Hyperinsulinaemia

Difficulty Washing Neck

Diet – try sugar free

Acanthosis Nigricans

ACCORD Study

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 2

Accord 3

5.0% Intensive group

4.0% Standard group

P= .02

Accord - Rate of death 4

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 1

Fasting Glucose 5.0 mmol/L (n3.5-6.0)

Fasting Insulin 116 pmol/L (n10-80)

Offered low sugar diet

Mr RC – Insulin 2

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 316 month follow up

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

Mr RC – Insulin 4

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

Emeritus Professor John Hunter

(1925-2003)

“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

Acne

Dairy

HyperkeratizationSebum Production Colonization

Acne

Possibly a corruption of “acme”

Acme = latin for a point or high spot

Acne

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.

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

Acne and Dairy

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

Normal weight

No hypertension

Low Insulin

Low leptin

No Acne

Kativan Islanders

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 1

Otherwise healthy

Normal build/BMI

Medication: Combined Oral Contraceptive

Nursing Student

Options?

Acne – Case SW 2

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 – SW 3

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

Acne - Conclusions

Source:Melnik ADV 2013

Treat Acne / Save the World?

• Celiac Disease – Dermatitis Herpetiformis

Eczema

Lupus

Rosacea

Gluten

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

anti TTG IgA: *** > 150 units (0 - 20)

Endomysial Ab: *** POSITIVE

Comment:

These results support a diagnosis of coeliac disease

Blood Tests

Clinical and Biopsy

IgG autoimmunity

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

Follow Up

Fasano

Scientific American

2009

1st Degree Relative 1:22

2nd Degree Relative 1:39

Symptoms 1:56

Not at risk 1:133

Family History

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

1914-2009

Father of the Green Revolution

Nobel Peace Prize 1970

Dwarf Wheat

Norman Borlaug

Alopecia areata

Aphthous stomatitis

Atopic dermatitis / Eczema

Cutaneous vasculitis

Dermatomyositis

Dermatitis herpetiformis

Oral lichen planus

Prurigo nodularis

Psoriasis

Urticaria

Vitiligo

Celiac disease and Skin disease

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

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

Eczema, unresponsive to topical steroids.

Consultation

“I have an intolerance to bread and scones”

Bloating

Follow up

Able to stop omeprazole

Lupus

Systemic

ANA+

Immune complex

Skin sometimes

Systemic Joints Internal organs

Antimalarial effect Weak/moderate

Cutaneous

Often negative

Cell mediated

Always Skin

Can have SLE as well

Strong

Lupus

58y F

2 biopsies confirm Lupus

Sb 2 dermatologists

Resistant to topical, and antimalarial

Works in science

F hx nil of note

Vegetarian / Piscatarian

ANA neg

Ttg 3 (0-20)

Gliadin IgG: 25 units(n<70)

Gliadin IgA: 5 units(n<15)

HLA DQ 2.2 and 2.5 pos

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

Skin much better but not fully settled

Could not take zinc

Eating more on GF diet

Has been able to stop omeprazole

RA/Lupus

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-gliadinDiet 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

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

Rosacea

Before and after #1

Before and after #2

“Mostly Gluten Free”

Breakfast – muesli

Lunch – Sandwich

Dinner – Pasta “a lot”

Snacks – includes cakes and biscuits

Breakfast

Morning Tea

Lunch

Afternoon Tea

Dinner

Supper

Snacks

Dietary Questionnaire:

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

Case to discuss - Radioiodine

Should She have it?

History

Family History

Celiac

Wheat Allergy

Gluten Intolerance

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

Family History

Skin almost clear

Prednisone not needed

Pentaza not restarted

Feels better in self

Now on 2 topical steroids and 6 monthly review

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

Tests

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

Gluten Free – Dr Strack's WaySummary of Patient Handout

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

Tobacco Potatoes Tomatoes Eggplant Peppers (bell peppers, chili peppers, paprika, tamales, tomatillos, pimentos, cayenne, etc) Goji Berries

Nightshade (Solanaceae) Family:

Deadly Nightshade / Belladonna

Steroid mimics Muscle tremors – cholinesterase inhibitors Only partlt removed with cooking Tobacco – Nicotine Potato, Tomato - Solanine Deadly Nightshade – Scopolamine

- Atropine

Nightshade Alkaloids

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 - Presentation

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 - Arthritis

Gene positive for Gluten sensitivity

Strongly positive anti-Gliadin antibody

Mr D S - Investigation

Seen 9/12 later

No arthritis this winter

No ankle swelling

Has not needed steroid injections in ankles

More energy

Mr D S - Follow up

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

inhibition of TXA2-dependent platelet aggregation

Blood half life 20min

Platelet life 10 days

Platelet recovery 10% per day

Aspirin

? 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

74y M

Lifelong dry skin – much worse last 6/12

Mother and brother also dry skin

Statin Stopped

Suggested two eggs for breakfast

Very Dry Skin

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

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

Norwegian HUNT 2 study

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

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

Conclusion

Junk Food

Sugar

Gluten

Carbohydrates

Levels of Intervention

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!

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!

Take Home Points

We are all different