Correlation of psoriasis and serum vitamin D

Abstract

Psoriasis is an immuno-mediated chronic systemic disease involving cytokines of helper Th1 pathway. Vitamin D has an effect on keratinocyte proliferation, differentiation and immune modulation of immune system especially Th1 pathway, which is altered in psoriatic skin suggesting that Vitamin D may have a role in pathogenesis of psoriasis.
To study correlation between psoriasis vulgaris and serum vitamin D.
To evaluate serum vitamin D level in psoriasis cases and in control group and correlating vitamin D level with severity and duration of the psoriasis.
57 cases (>15years of age) with psoriasis and 57 healthy subjects were recruited. Psoriasis was clinically diagnosed and severity evaluated by PASI scale. Vitamin D was analysed by enhanced chemilumine scence on vitrus Eci autoanalyzer of Orth clinical diagnostic. Vitamin D deficiency defined as <20ng/ml, insufficiency 20-30ng/ml and sufficient 30-100ng/ml.
Vitamin D deficiency in the study was 22.8% in patients and 14% in control group. Vitamin D insufficiency was found in 42.1% of cases and 19.3% of control. According to chi-square the p-value is 0.003 showing significant association. There was a tendency towards decrease in vitamin D level with increase in disease duration. There was negative correlation between vitamin D and PASI score.
The study found a significant relationship between vitamin D and psoriasis. Further metanalysis involving larger study population will be required to establish whether vitamin D levels benefits patient with psoriasis vulgaris.

Full text

IP Indian Journal of Clinical and Experimental Dermatology 2021;7(4):320–323
Content available at: https://www.ipinnovative.com/open-access-journals
IP Indian Journal of Clinical and Experimental Dermatology
Journal homepage: www.ijced.org/
Original Research Article
Correlation of psoriasis and serum vitamin D
Krishnendra Varma1, Ujjwal Kumar1, Ritika Gujrati1,*
1Dept. of Dermatology, R. D. Gardi Medical College, Ujjain, Madhya Pradesh, India
ARTICLE INFO
Article history:
Received 21-10-2021
Accepted 09-11-2021
Available online 11-12-2021
Keywords:
Serum Vitamin D
Psoriasis severity and Disease
duration
ABSTRACT
Background: Psoriasis is an immuno-mediated chronic systemic disease involving cytokines of helper Th1
pathway. Vitamin D has an effect on keratinocyte proliferation, differentiation and immune modulation of
immune system especially Th1 pathway, which is altered in psoriatic skin suggesting that Vitamin D may
have a role in pathogenesis of psoriasis.
Aim: To study correlation between psoriasis vulgaris and serum vitamin D.
Objective: To evaluate serum vitamin D level in psoriasis cases and in control group and correlating
vitamin D level with severity and duration of the psoriasis.
Materials and Methods: 57 cases (>15years of age) with psoriasis and 57 healthy subjects were recruited.
Psoriasis was clinically diagnosed and severity evaluated by PASI scale. Vitamin D was analysed by
enhanced chemilumine scence on vitrus Eci autoanalyzer of Orth clinical diagnostic. Vitamin D deficiency
defined as <20ng/ml, insufficiency 20-30ng/ml and sufficient 30-100ng/ml.
Results: Vitamin D deficiency in the study was 22.8% in patients and 14% in control group. Vitamin D
insufficiency was found in 42.1% of cases and 19.3% of control. According to chi-square the p-value is
0.003 showing significant association. There was a tendency towards decrease in vitamin D level with
increase in disease duration. There was negative correlation between vitamin D and PASI score.
Conclusion: The study found a significant relationship between vitamin D and psoriasis. Further
metanalysis involving larger study population will be required to establish whether vitamin D levels benefits
patient with psoriasis vulgaris.
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1. Introduction
Psoriasis is a multi-factorial chronic inflammatory skin
disease. It is characterized by erythematous, oedematous
plaque with silvery white micaceous scale. Histologically,
there is disordered keratinization with increase cell
turn-over, perivascular mixed inflammatory infiltrate and
tortuous, dilated vessels. The prevalence varies from 0.44%
- 2.8% in India;1with equal sex ratio and bimodal age of
onset.
* Corresponding author.
E-mail address:gujrati.ritika10@gmail.com (R. Gujrati).
Its aetiology is unknown; involving various
environmental, genetic and immunological factors. On
the basis of HLA-Cw6 association it is divided into type
1 psoriasis which is early onset HLA associated and
type 2 psoriasis which is late onset HLA not associated.
According to genome wide association studies there are
mainly 9 psoriasis susceptible genes (PSORS 1-9) known
which accounts for psoriasis risk. It involves both type of
immune system with classical involvement of Th1, Th17,
Th22 pathway.
Upon damage to keratinocyte due to any cause
in psoriasis susceptible individual there is increased
production of antimicrobial peptide (LL-37) and various
https://doi.org/10.18231/j.ijced.2021.060
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cytokines mainly TNF alpha, INF gamma, IL 6, IL 1beta,
IL 12, IL 23 via activated dendritic cell resulting in
T cell differentiation, keratinocyte hyper-proliferation and
neutrophil and lymphocyte infiltration forming a psoriatic
plaque. There is a cross-talk between epidermal and dermal
cells with release of various growth factors and chemokines
forming a self-perpetuating inflammatory loop.
Psoriasis is classified into many types, most common
being chronic plaque psoriasis also known as psoriasis
vulgaris.
Vitamin D functions as a hormone and synthesized
via photochemical reaction in the skin by UVB radiation
and hydroxylation of ProvitaminD3 (7-dehydrocholesterol)
in liver and kidney.2The active form of vitamin D
[25(OH)D] through Vitamin D receptor (VDR) which
is present on keratinocyte and T cells. It regulates
keratinocyte maturation, apoptosis, cutaneous immune
response via influencing dendritic and T cell function,
inducing regulatory T cell and shifting towards Th2 profile
and down regulating various cytokines including IL-2, IL-
6 and IL-12, IFN-γ, TNF-αand TNFβ, also suppresses
NK cell and neutrophil functions thereby exerting anti-
inflammatory, immuno-modulatory and anti-proliferative
effect.3–6
Current knowledge has stressed upon the immuno-
modulating effect of vitamin D and its usefulness in
reducing clinical severity and long term need of medication
with altering the risk profile for several metabolic disorder.
With this in mind, we investigated the serum vitamin
D levels in patient with psoriasis and healthy controls to
understand whether vitamin D levels has a role in psoriasis
pathogenesis or severity.
2. Materials and Methods
Clinically diagnosed 57 patients of chronic plaque psoriasis
and 57 healthy controls were studied during a period of
January 2020 – December 2020.
This was an observational case-control study where
detailed and informed consent was taken from both the
groups. A detailed history was inquired and clinical
examination was done with evaluation of serum vitamin D
levels.
2.1. Inclusion criteria
Clinically diagnosed chronic plaque psoriasis patients and
healthy controls of age > 15 years of any sex.
2.2. Exclusion criteria
Other types of psoriasis patient and those on treatment,
which might influence vitamin D status.
3. Results
A total of 114 subjects participated in the study with
majority (37.7%) belonged to 55-65 years of age group
having male predominance (71.9%).
There was 18.4 % prevalence of vitamin D deficiency in
the study subjects.
Vitamin D deficiency (<20 ng/ml) was seen in 22.8% of
cases and 14% of control group, whereas insufficiency (20-
30ng/ml) was seen in 42.1% of cases and 19.3% of controls.
Fig. 1: Association between and vitamin D level
Majority of cases (56.1%) belonged to 1-5 years of
disease duration.
Most of cases with higher vitamin D deficiency (53.8%)
belonged to moderate (3-10) PASI score category.
Bulk of cases (47.4%) belonged to severe (>10) PASI
category with mean vitamin D level 26.94 ±7.19 ng/ml.
We found a significant (p<0.01) association of vitamin D
levels among cases and controls.
We observed significant(p<0.000) difference of vitamin
D levels in cases and control group with mean vitamin D
level in case was 31.55±15.76 ng/ml and in control was
42.59±16.92 ng/ml.
We found a negative correlation of vitamin D levels with
duration of disease r=-0.481, p = 0.000.
We observed a negative correlation of vitamin D levels
with PASI psoriasis severity score r=-0.523, p = 0.000.
4. Discussion
In the present study, majority of psoriasis cases belonged
to the 55-65 years of age group [31.6%]. The mean
age of psoriasis in cases was 46.912 ±14.77 years and
50.73±13.95 years in control group. This mean age is almost
same as reported by Srirama L et al in an Indian study.7
In this study, majority [68 (59.6%)] of patients belonged
to rural areas may be because the study was done in semi-
urban area.
We observed 18.4% prevalence of vitamin D deficiency
in our study. This finding was similar to study done in Egypt
by Hesham Abd El-Moaty Zaher et al.8We also observed
prevalence of vitamin D insufficiency to be 30.7% in study

322 Varma, Kumar and Gujrati / IP Indian Journal of Clinical and Experimental Dermatology 2021;7(4):320–323
Table 1: Association between group and vitamin D level
Vitamin D Group Total
Cases Controls
Deficiency (<20 ng/ml) 13 8 21
22.8% 14.0% 18.4%
Insufficiency (20-30 ng/ml) 24 11 35
42.1% 19.3% 30.7%
Sufficient (30-100 ng/ml) 20 38 58
35.1% 66.7% 50.9%
Total 57 57 114
100.0% 100.0% 100.0%
Chi-square=11.605; p=0.003
group. We found a significant association between vitamin
D and cases and controls (p <0.01).
The mean vitamin D among cases were 31.55 ±15.76
ng/ml and controls were 42.59 ±16.92 ng/ml. This showed
a highly significant difference of vitamin D levels between
cases and controls (p < 0.000). This result was found to be
consistent when compared with the other studies done in
other parts of the world.
El-Moaty Zaher et al conducted a case control study in
40 psoriatic patient v/s 40 healthy controls which showed
a significant difference in vitamin D levels with p < 0.000,
another comparison study consisting of 200 subjects done
by Al-Mutairi et al found significant difference in vitamin
D levels with p<0.0001.8,9
We observed that higher percentage [6 cases] of vitamin
D deficiency was in 5-10 years of disease duration, while
insufficiency [17 cases] was higher in 1-5 years of disease
duration.
There was negative correlation of disease duration with
vitamin D levels (p = 0.000) in our study with the mean
vitamin D level was 21.38 ±7.63 ng/ml in psoriatic
patients with >10 years of disease duration. This finding was
consistent with that reported in a meta-analysis.10
The mean vitamin D levels in Severe PASI category was
found to be lowest (26.94 ±7.19 ng/ml) among 3 PASI
group. We found a significant correlation of mean vitamin
D levels with PASI score category (p=0.000) which was
similar to that observed by Stoyan et al.11
It is now considered that psoriasis is a systemic
inflammatory disease, mainly involving Th1-Th17-Th22
immune pathway. It presents as abnormal keratinocyte
hyperproliferation and infiltration of inflammatory cells.
Vitamin D is known to regulate at physiological level
cell differentiation and proliferation, immune modulation,
expression of K1 and K10 and normal distribution of
integrins. These suggests that vitamin D may have a role
in psoriasis. The serum level of vitamin D is affected by
various factors like polymorphism or deficiency of Vitamin
D receptor (VDR), which is required for active vitamin D
uptake and function, less dietary intake or intake of food
items or drug which interfere with vitamin D synthesis
and activation, adequate sun-exposure and clothing for
cutaneous synthesis of vitamin D which is disturbed as
psoriasis patient tend to cover their affected area. Various
metabolic disorder tends to reduce the bioavailability of
circulating vitamin D via accumulating it in fat cells.
5. Conclusion
To conclude, our study showed a significant correlation of
psoriasis with vitamin D but it is still not clear to say
that serum vitamin D levels interfere with psoriasis disease
duration or severity. Further meta-analysis is required to
understand the exact correlation.

Varma, Kumar and Gujrati / IP Indian Journal of Clinical and Experimental Dermatology 2021;7(4):320–323 323
6. Source of Funding
There was no financial support received for the work.
7. Conflict of Interest
The author has no conflict of interest to declare.
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Author biography
Krishnendra Varma, Professor and Head
Ujjwal Kumar, Professor
Ritika Gujrati, 3rd Year Resident
Cite this article: Varma K, Kumar U, Gujrati R. Correlation of
psoriasis and serum vitamin D. IP Indian J Clin Exp Dermatol
2021;7(4):320-323.