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Complete resolution of guttate psoriasis after tonsillectomy.

Psoriasis is a chronic, inflammatory, immune-mediated disease that affects 3.2% of adults in the United States. (1) Streptococcal infections have been associated with several systemic disease processes including glomerulonephritis and rheumatic heart disease. A well-established link between psoriasis and streptococcal infection also has been reported in the literature. (1,2) Specifically, this association appears to be with both guttate and plaque psoriasis.

Although the exact etiology is unclear, it is believed that a streptococcal trigger residing in the palatine tonsils might activate T cells in the skin through molecular mimicry. (1) HLA-Cw*0602 homozygosity hasbeen linked to streptococcal-associated psoriasis. (3) Several studies have reported improvement or complete resolution of psoriasis after tonsillectomy. (1,2,4-8)

A 26-year-old man presented to our office with a history of recurrent streptococcal tonsillitis. One episode of tonsillitis was treated with oral levofloxacin by his primary care physician. However, because the patient developed joint pain after several days of treatment, it was discontinued.

Two weeks later, the patient began to develop a rash over his hands (figure 1), trunk, back, and extremities. The patient was evaluated by a dermatologist and was subsequently diagnosed with guttate psoriasis. It was further described as a salmon-pink, teardrop-shaped papular rash with a fine scale. This rash was treated with topical steroids.

Several months later the rash resolved, but it returned with another episode of tonsillitis. Given the recurrent episodes of tonsillitis, the patient underwent tonsillectomy 2 months later. After surgery, the rash completely resolved (figure 2). On his back, some hypopigmented lesions from scarring remained, but these are expected to improve over time. The patient currently does not require treatment for psoriasis; his rash has not returned to date.

Several studies have demonstrated the efficacy of tonsillectomy for the treatment of streptococcal-associated psoriasis. One meta-analysis revealed that 290 of 410 (70.7%) patients with psoriasis who underwent tonsillectomy experienced improvement of their psoriasis. (1) The authors concluded that evidence is insufficient to support tonsillectomy in most patients with psoriasis. However, a tonsillectomy might be beneficial when psoriasis exacerbations are closely associated with recurrent tonsillitis. (1)

A randomized, controlled trial demonstrated that patients with plaque psoriasis undergoing tonsillectomy had significantly improved health-related quality of life and psoriasis-related stress. (5) A Cochrane database protocol states that adult tonsillectomy for psoriasis is beneficial, but the evidence for this is not robust. (6)

It has been shown, especially with guttate psoriasis, that tonsillectomy has a potential benefit in psoriasis disease burden. (1,5,7,8) Our patient demonstrated complete recovery after tonsillectomy. The decision to perform a tonsillectomy in this case was appropriate because the patient's psoriasis flares corresponded with episodes of tonsillitis. It is important to highlight this case because it involved an adult, although tonsillitis-associated guttate psoriasis is typically reported in the pediatric population. (4,7,8) Additionally, we demonstrated a significant improvement in this disease process with photographic evidence. Future prospective studies looking at the efficacy of tonsillectomy on psoriasis are encouraged.

References

(1.) Rachakonda TD, Dillon JS, Florek AG, Armstrong AW. Effect of tonsillectomy on psoriasis: A systematic review. J Am Acad Dermatol 2015;72(2):261-75.

(2.) Sigurdardottir SL, Thorleifsdottir RH, Valdimarsson H, Johnston A. The role of the palatine tonsils in the pathogenesis and treatment of psoriasis. Br J Dermatol 2013;168(2):237-42.

(3.) Thorleifsdottir RH, Sigurdardottir SL, Sigurgeirsson B, et al. HLA-Cw6 homozygosity in plaque psoriasis is associated with streptococcal throat infections and pronounced improvement after tonsillectomy: A prospective case series. J Am Acad Dermatol 2016;75(5):889-96.

(4.) Saita B, Ishii Y, Ogata K, et al. Two sisters with guttate psoriasis responsive to tonsillectomy: Case reports with HLA studies. J Dermatol 1979;6(3):185-9.

(5.) Thorleifsdottir RH, Sigurdardottir SL, Sigurgeirsson B, et al. Patient-reported outcomes and clinical response in patients with moderate-to-severe plaque psoriasis treated with tonsillectomy: A randomized controlled trial. Acta Derm Venereol 2017;97(3): 340-5.

(6.) Owen CM, Chalmers RJ, O'Sullivan T, Griffiths CE. Antistreptococcal interventions for guttate and chronic plaque psoriasis. Cochrane Database Syst Rev 2000(2):CD001976.

(7.) Hone SW, Donnelly MJ, Powell F, Blayney AW. Clearance of recalcitrant psoriasis after tonsillectomy. Clin Otolaryngol Allied Sei 1996;21(6):546-7.

(8.) McMillin BD, Maddern BR, Graham WR. A role for tonsillectomy in the treatment of psoriasis? Ear Nose Throat J 1999;78(3):155-8.

Jason E. Cohn, DO; Michael Pfeiffer, DO; Gerard Vernose, MD

Caption: Figure 1. Photo shows the guttate psoriasis on the patient's hands before tonsillectomy.

Caption: Figure 2. This photo shows the patient's hands 2 months after tonsillectomy. The psoriasis has resolved completely.

From the Department of Otolaryngology-Head and Neck Surgery, Philadelphia College of Osteopathic Medicine (Dr. Cohn and Dr. Pfeiffer); and the Department of Otolaryngology-Head and Neck Surgery, Jefferson Health-Methodist Hospital (Dr. Vernose), Philadelphia.
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Title Annotation:SPECIAL TOPICS CLINIC
Author:Cohn, Jason E.; Pfeiffer, Michael; Vernose, Gerard
Publication:Ear, Nose and Throat Journal
Article Type:Case study
Geographic Code:1USA
Date:Mar 1, 2018
Words:792
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