Is there a link between tonsils and psoriasis? Taubman Emerging Scholar Dr. Johann Gudjonsson investigates

 

Treating patients with disfiguring skin diseases has spurred Taubman Emerging Scholar Dr. Johann Gudjonsson to seek new insights into what causes psoriasis and other inflammatory conditions.

Recently, Dr. Gudjonsson and colleagues presented intriguing findings about the role of the tonsils in the disease.  In a first-of-its kind study, they found that chronic psoriasis patients who had their tonsils removed showed improvement that lasted the entire two years of the study, and that the patients required less treatment.  

Determining new ways to treat psoriasis is key in alleviating the physical suffering, emotional distress and financial costs associated with the disease, which affects more than four million Americans at an estimated annual cost of more than $11 billion.

It’s more than a cosmetic condition. In addition to the outward symptoms of the disease, patients with psoriasis commonly have depression and anxiety, thoughts of suicide, and an increased risk of lymphoma.  They are at greater risk for heart attacks and metabolic syndrome, and those with severe forms of the disease die on average 3.5 to 4.4 years younger than people without psoriasis.

So, what do tonsils have to do with the health of our skin?

It appears that psoriasis may be triggered -- in people who already have a genetic predisposition to the disease -- by a streptococcal throat infection occurring at a particular time in a teen or young adult’s life, jumpstarting the body’s immune response.

“If you don’t get the right stimulus at the right time, you are probably not going to get psoriasis,” Dr. Gudjonsson said.  

There's a theory that psoriasis is a sort of good thing gone bad; it occurs when a protective mechanism in the body goes haywire and produces an excess of inflammatory response to streptococcal throat infections or injury.  In this extreme response, the inflammatory responses trigger the development of the lesions that are characteristic of psoriasis.

"The tonsils are where the immune system is constantly sampling what we eat and what we are in contact with in our environment,” said Dr. Gudjonsson. “They’re like a sensor between the gut and the skin.”

And since tonsils feeling a threat can send out the same sort of T cells (a special type of infection-fighting cell) to the skin as the skin itself does when it’s under threat, Dr. Gudjonsson and colleagues wondered what would happen if the tonsils and their ability to generate those cells were removed. 

Fewer T cells might mean less stimulation of the response that leads to psoriasis flare-ups. That was the theory, and the study of 29 adult patients with chronic plaque psoriasis showed intriguing results.  Fifteen of the subjects received tonsillectomies, and within two months showed marked reduction in skin lesions and other measures of the disease – and the improvements were maintained throughout the two years the patients were followed.  

“It gives us an avenue to explore,” Dr. Gudjonsson said of the study.  “Perhaps we could take out the tonsils at the first eruption and get the patient into permanent remission. And tonsillectomy is a fraction of the cost of long-term treatment, which can cost $20,000 to $40,000 a year.”

Meanwhile, Dr. Gudjonsson, the Frances and Kenneth Eisenberg Emerging Scholar and an assistant professor of dermatology at the University of Michigan Medical School, continues to pursue other research related to inflammatory skin diseases, in addition to teaching, writing, seeing patients and supervising his laboratory.

One project, in collaboration with U-M’s Dr. James T. Elder, is looking at DNA samples from 30,000 people – 10,000 with psoriasis and 20,000 healthy controls – to identify genes and mutations that make someone predisposed to psoriasis.  Screening that many genetic samples is a new approach thanks to current computer power and the science of bioinformatics; “This would not have been doable 10 years ago,” said Dr. Gudjonsson. 

This work, which was recently published in Nature Genetics, added 15 new risk genes to the list of genes now known to predispose to psoriasis.

He’s also preparing for a large clinical trial that will help determine why patients with the same form of psoriasis respond differently to the same treatment; some 50 patients will take part in the initial study.

Dr. Gudjonsson said funding from the Taubman Emerging Scholars program has been vital to his ability to blend research with patient practice, and to allow him to pursue novel areas of inquiry.

“That somebody is willing to take an interest in your work, particularly at this early formative stage of my career, is amazing to me,” he said. “I’m very grateful for this support. 

"It’s been incredibly helpful as it has allowed me to take on projects that I’d otherwise never have been able to do, including higher-risk projects that have led to new avenues in my research and something that I hope will translate to better treatment, and hopefully eventually a cure, for my patients.”

 


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