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