Case Reports

Clearance of Psoriasis After Ischemic Stroke

Cutis. 2019 February;103(2):74-76

The role of the nervous system in the pathogenesis of psoriasis is not well elucidated. However, its involvement is clinically apparent with sparing of areas affected by neurologic disease, such as poliomyelitis, and remission of psoriasis in cases of nerve damage. Several neuropeptides, including substance P (SP), nerve growth factor, calcitonin gene-related peptide, and vasoactive intestinal peptide have been hypothesized to play a part in the development of psoriasis and its symptoms. We report a case of a patient with psoriasis who experienced complete remission following ischemic stroke.

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Practice Points

Psoriasis is exacerbated in the presence of stress, and psoriatic lesions often have a symmetric distribution, which is evidence that the nervous system is involved in the pathophysiology of the condition.
Various neuropeptides are involved in the pathophysiology of psoriasis, including substance P, nerve growth factor, calcitonin gene-related peptide, and vasoactive intestinal peptide.
Peripheral nerve damage results in decreased secretion of neuropeptides, which can lead to remission of psoriasis.

References

Boehncke WH. Etiology and pathogenesis of psoriasis. Rheum Dis Clin North Am. 2015;41:665-675.
Saraceno R, Kleyn CE, Terenghi G, et al. The role of neuropeptides in psoriasis. Br J Dermatol. 2006;155:876-882.
Ostrowski SM, Belkai A, Loyd CM, et al. Cutaneous denervation of psoriasiform mouse skin improves acanthosis and inflammation in a sensory neuropeptide-dependent manner. J Invest Dermatol. 2011;131:1530-1538.
Dewing SB. Remission of psoriasis associated with cutaneous nerve section. Arch Dermatol. 1971;104:220-221.
Stratigos AJ, Katoulis AK, Stavrianeas NG. Spontaneous clearing of psoriasis after stroke. J Am Acad Dermatol. 1998;38(5, pt 1):768-770.
Raychaudhuri SP, Farber EM. Neuroimmunologic aspects of psoriasis. Cutis. 2000;66:357-362.
Farber EM, Nickoloff BJ, Recht B, et al. Stress, symmetry, and psoriasis: possible role of neuropeptides. J Am Acad Dermatol. 1986;14(2, pt 1):305-311.
Al’Abadie MS, Senior HJ, Bleehen SS, et al. Neuropeptides and general neuronal marker in psoriasis—an immunohistochemical study. Clin Exp Dermatol. 1995;20:384-389.
Pincelli C, Fantini F, Romualdi P, et al. Substance P is diminished and vasoactive intestinal peptide is augmented in psoriatic lesions and these peptides exert disparate effects on the proliferation of cultured human keratinocytes. J Invest Dermatol. 1992;98:421-427.
Zhu TH, Nakamura M, Farahnik B, et al. The role of the nervous system in the pathophysiology of psoriasis: a review of cases of psoriasis remission or improvement following denervation injury. Am J Clin Dermatol. 2016;17:257-263.
Pincelli C. Nerve growth factor and keratinocytes: a role in psoriasis. Eur J Dermatol. 2000;10:85-90.
Raychaudhuri SP, Jiang WY, Farber EM. Psoriatic keratinocytes express high levels of nerve growth factor. Acta Derm Venereol. 1998;78:84-86.
He Y, Ding G, Wang X, et al. Calcitonin gene‐related peptide in Langerhans cells in psoriatic plaque lesions. Chin Med J (Engl). 2000;113:747-751.
Chu DQ, Choy M, Foster P, et al. A comparative study of the ability of calcitonin gene‐related peptide and adrenomedullin_13–52 to modulate microvascular but not thermal hyperalgesia responses. Br J Pharmacol. 2000;130:1589-1596.
Nakamura M, Toyoda M, Morohashi M. Pruritogenic mediators in psoriasis vulgaris: comparative evaluation of itch-associated cutaneous factors. Br J Dermatol. 2003;149:718-730.
Wang TS, Tsai TF. Psoriasis sparing the lower limb with postpoliomeylitis residual paralysis. Br J Dermatol. 2014;171:429-431.
Weiner SR, Bassett LW, Reichman RP. Protective effect of poliomyelitis on psoriatic arthritis. Arthritis Rheum. 1985;28:703-706.
Cohen AD, Bonneh DY, Reuveni H, et al. Drug exposure and psoriasis vulgaris: case control and case-crossover studies. Acta Derm Venereol. 2005;85:299-303.
Faghihi T, Radfar M, Mehrabian Z, et al. Atorvastatin for the treatment of plaque-type psoriasis. Pharmacotherapy. 2011;31:1045-1050.
Chua SHH, Tioleco GMS, Dayrit CAF, et al. Atorvastatin as adjunctive therapy for chronic plaque type psoriasis versus betamethasone valerate alone: a randomized, double-blind, placebo-controlled trial. Indian J Dermatol Venereol Leprol. 2017;83:441-447.
Jekel LG. Use of heparin in treatment of psoriasis. AMA Arch Derm Syphilol. 1953;68:80-82.
Farber EM, Cohen EN, Trozak DJ, et al. Peptide T improves psoriasis when infused into lesions in nanogram amounts. J Am Acad Dermatol. 1991;25:658-664.

The etiology of psoriasis is multifactorial, and it is attributed to both genetic and environmental components.¹ One of the lesser-studied aspects of psoriasis pathogenesis is the involvement of the nervous system. It is thought that the pathogenesis involves inflammation of the cutaneous nerves,² and cutaneous denervation has been shown to improve acanthosis and IL-23 expression in mice with psoriasiform skin.³ There also have been reports of psoriasis remission following peripheral and central nervous system injury from surgical nerve resection⁴ as well as cerebrovascular accident.⁵ We present a case of total psoriasis clearance following ischemic stroke.

Case Report

A 52-year-old man with psoriasis presented to the dermatology clinic for follow-up. The patient had been using topical clobetasol and apremilast with limited success but had not previously tried biologics. On physical examination he was noted to have erythematous, scaly, indurated papules and plaques on the chest, abdomen, back, arms, and legs, consistent with psoriasis. Affected body surface area was approximately 10%. Ustekinumab was prescribed, but the patient did not pick it up from the pharmacy.

Approximately 1 month later, the patient presented to the emergency department with left-sided weakness and numbness. He was hospitalized for treatment of stroke. During hospitalization, the patient was started on lisinopril, aspirin, and atorvastatin. He also was given subcutaneous enoxaparin with plans to initiate warfarin as an outpatient. His psoriasis was not treated with topical or systemic medications during the course of his admission. He was discharged to a skilled nursing facility after 3 days.

Three months following discharge, the patient returned to the dermatology clinic for follow-up. After his stroke, he reported that his psoriasis had cleared and had not returned. On physical examination his skin was clear of psoriatic lesions.

Comment

The nervous system is thought to play an important role in the pathophysiology of psoriasis. Evidence for this involvement includes the exacerbation of psoriasis with stress and the often symmetric distribution of psoriatic lesions.⁶

References

Boehncke WH. Etiology and pathogenesis of psoriasis. Rheum Dis Clin North Am. 2015;41:665-675.
Saraceno R, Kleyn CE, Terenghi G, et al. The role of neuropeptides in psoriasis. Br J Dermatol. 2006;155:876-882.
Ostrowski SM, Belkai A, Loyd CM, et al. Cutaneous denervation of psoriasiform mouse skin improves acanthosis and inflammation in a sensory neuropeptide-dependent manner. J Invest Dermatol. 2011;131:1530-1538.
Dewing SB. Remission of psoriasis associated with cutaneous nerve section. Arch Dermatol. 1971;104:220-221.
Stratigos AJ, Katoulis AK, Stavrianeas NG. Spontaneous clearing of psoriasis after stroke. J Am Acad Dermatol. 1998;38(5, pt 1):768-770.
Raychaudhuri SP, Farber EM. Neuroimmunologic aspects of psoriasis. Cutis. 2000;66:357-362.
Farber EM, Nickoloff BJ, Recht B, et al. Stress, symmetry, and psoriasis: possible role of neuropeptides. J Am Acad Dermatol. 1986;14(2, pt 1):305-311.
Al’Abadie MS, Senior HJ, Bleehen SS, et al. Neuropeptides and general neuronal marker in psoriasis—an immunohistochemical study. Clin Exp Dermatol. 1995;20:384-389.
Pincelli C, Fantini F, Romualdi P, et al. Substance P is diminished and vasoactive intestinal peptide is augmented in psoriatic lesions and these peptides exert disparate effects on the proliferation of cultured human keratinocytes. J Invest Dermatol. 1992;98:421-427.
Zhu TH, Nakamura M, Farahnik B, et al. The role of the nervous system in the pathophysiology of psoriasis: a review of cases of psoriasis remission or improvement following denervation injury. Am J Clin Dermatol. 2016;17:257-263.
Pincelli C. Nerve growth factor and keratinocytes: a role in psoriasis. Eur J Dermatol. 2000;10:85-90.
Raychaudhuri SP, Jiang WY, Farber EM. Psoriatic keratinocytes express high levels of nerve growth factor. Acta Derm Venereol. 1998;78:84-86.
He Y, Ding G, Wang X, et al. Calcitonin gene‐related peptide in Langerhans cells in psoriatic plaque lesions. Chin Med J (Engl). 2000;113:747-751.
Chu DQ, Choy M, Foster P, et al. A comparative study of the ability of calcitonin gene‐related peptide and adrenomedullin_13–52 to modulate microvascular but not thermal hyperalgesia responses. Br J Pharmacol. 2000;130:1589-1596.
Nakamura M, Toyoda M, Morohashi M. Pruritogenic mediators in psoriasis vulgaris: comparative evaluation of itch-associated cutaneous factors. Br J Dermatol. 2003;149:718-730.
Wang TS, Tsai TF. Psoriasis sparing the lower limb with postpoliomeylitis residual paralysis. Br J Dermatol. 2014;171:429-431.
Weiner SR, Bassett LW, Reichman RP. Protective effect of poliomyelitis on psoriatic arthritis. Arthritis Rheum. 1985;28:703-706.
Cohen AD, Bonneh DY, Reuveni H, et al. Drug exposure and psoriasis vulgaris: case control and case-crossover studies. Acta Derm Venereol. 2005;85:299-303.
Faghihi T, Radfar M, Mehrabian Z, et al. Atorvastatin for the treatment of plaque-type psoriasis. Pharmacotherapy. 2011;31:1045-1050.
Chua SHH, Tioleco GMS, Dayrit CAF, et al. Atorvastatin as adjunctive therapy for chronic plaque type psoriasis versus betamethasone valerate alone: a randomized, double-blind, placebo-controlled trial. Indian J Dermatol Venereol Leprol. 2017;83:441-447.
Jekel LG. Use of heparin in treatment of psoriasis. AMA Arch Derm Syphilol. 1953;68:80-82.
Farber EM, Cohen EN, Trozak DJ, et al. Peptide T improves psoriasis when infused into lesions in nanogram amounts. J Am Acad Dermatol. 1991;25:658-664.

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Clearance of Psoriasis After Ischemic Stroke

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