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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 34  |  Issue : 1  |  Page : 56-60

The value of calcium and high-sensitivity C-reactive protein serum levels in psoriatic patients


1 Department of Dermatology, Andrology and STDs, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Medical Biochemistry and Molecular Biology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
3 Department of Dermatology, Ministry of Health, Menoufia, Egypt

Date of Submission06-Aug-2019
Date of Decision02-Sep-2019
Date of Acceptance06-Sep-2019
Date of Web Publication27-Mar-2021

Correspondence Address:
Shaimaa B El Hagary
Shiben Elkome, Menoufia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_227_19

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  Abstract 


Objective
The aim was to evaluate the level of serum calcium and the serum level of high-sensitivity C-reactive protein (hsCRP) in patients with psoriasis.
Background
Psoriasis is a systemic chronic inflammatory disease of the skin with associated comorbidity. The most detrimental aspect of psoriasis is the concurrent physical comorbidities, such as cardiovascular disease, obesity, diabetes, metabolic syndrome, inflammatory bowel disease, and psoriatic arthritis that contribute to decreased longevity. Psoriasis is one of the skin diseases that have been found to show disturbance in systemic calcium metabolism. CRP is one of the acute-phase reactant proteins, and its blood level increases during inflammatory reactions. There is a link between the concentration of CRP and cardiovascular disease development in psoriatic patients.
Patients and methods
Psoriatic patients (n = 40) and age, sex-matched, and BMI-matched healthy controls (n = 40) were enrolled. Serum levels of hsCRP were measured by enzyme-linked immunosorbent assay, and assessment of serum calcium was done using enzymatic colorimetric technique.
Results
Serum calcium (P < 0.001) and serum hsCRP (P < 0.001) showed significant differences compared with controls.
Conclusion
Several biomarkers are altered in patients with psoriasis. In particular, decrease in serum calcium and increase in serum hsCRP could be of interest for further studies. A longitudinal observation study on levels of these biomarkers in response to treatment as well as a correlation of these markers with the development of concomitant diseases in patients with moderate-to-severe psoriasis should be initiated.

Keywords: calcium, cardiovascular, comorbidity, high-sensitivity C-reactive protein, psoriasis


How to cite this article:
Basha MA, Shehata WA, Gayed IM, El Hagary SB. The value of calcium and high-sensitivity C-reactive protein serum levels in psoriatic patients. Menoufia Med J 2021;34:56-60

How to cite this URL:
Basha MA, Shehata WA, Gayed IM, El Hagary SB. The value of calcium and high-sensitivity C-reactive protein serum levels in psoriatic patients. Menoufia Med J [serial online] 2021 [cited 2021 Oct 23];34:56-60. Available from: http://www.mmj.eg.net/text.asp?2021/34/1/56/312019




  Introduction Top


Psoriasis is a chronic inflammatory skin disease affecting 2–3% of worldwide population [1]. Psoriasis has significant associated comorbidities, with cardio-metabolic dysfunction and psoriatic arthritis being at the forefront [2]. Psoriasis results from interplay between genetic susceptibility, skin barrier defect, and deregulation of innate and adaptive immunity [3].

Although the initial events triggering a psoriatic lesion are unknown, many environmental factors have been shown to play a role in psoriasis pathogenesis [4].

Histologically, the dermatosis is characterized by hyperproliferation of keratinocytes, impaired epidermal barrier function at the sites of skin lesions, and skin infiltration by activated inflammatory cells [5].

Psoriasis is identified as a multisystem disease, with common comorbidities such as psoriatic arthritis, cardiovascular disease (CVD), metabolic syndrome, and inflammatory bowel disease [6].

Intracellular calcium plays an important role in the regulation of proliferation and differentiation of keratinocytes [7]. However, in psoriasis and some others skin diseases, there are disturbance in systemic calcium metabolism. Association of mild hypocalcemia with pustular psoriasis has been observed [8]. Moreover, hypoparathyroidism may cause the onset or aggravate psoriasis. In addition, topical application of 1,25-2(OH), D, a well-known calcitropic hormone, improves the skin lesion in psoriatic patient [9].

C-reactive protein (CRP) is one of the acute-phase reactant proteins produced by hepatocytes and adipocytes, and its blood level increases during inflammatory reactions [10]. Determination of high-sensitivity C-reactive protein (hsCRP) has been suggested to be more sensitive than conventional measurement of CRP and provides better sensitivity in confirmation of inflammation, and its expression in inflammatory dermatoses made it a candidate marker of inflammation [11].

The aim of this study was to evaluate the level of serum calcium and serum hsCRP in patients with psoriasis.


  Patients and methods Top


Study population

This case–control study was conducted at Dermatology, Andrology and STDs and Medical Biochemistry Departments, Faculty of Medicine, Menoufia University. A total of 40 patients with variable degrees of psoriasis severity and 40 age-matched, sex-matched, and BMI-matched healthy volunteers were included in this study.

Ethics

A written consent form approved by Local Ethical Research Committee in Menoufia Faculty of Medicine was obtained from every participant before study initiation. This was in accordance with Helsinki declaration of 1974 (revised in 2000).

Inclusion criteria

Patients with psoriasis vulgaris of both sexes who did not receive any systemic/topical immunosuppressant or immunomodulator drugs for a minimum of 15 days before blood sampling were included.

Exclusion criteria

Any patient or control with any dermatological disease other than psoriasis vulgaris and/or a history of other inflammatory or immune-mediated inflammatory diseases was excluded. Any patient or control with BMI more than 30 were excluded as well. Weight gain and obesity are considered as a low-grade inflammatory conditions. Therefore, obese patients were excluded in order not to affect the results.

All enrolled participants were subjected to the following: (a) medical history: a purposely designed sheet was performed, including relevant personal data, such as age, sex, residence, occupation, marital status, and special habits, for example, smoking, present history such as onset, duration, and extent of disease and its duration, and past history of medical diseases or drug intake and family history of psoriasis. (b) Thorough clinical examination included evaluation of vital signs including blood pressure and body weight and height to assess BMI [12]. Full dermatological examination was done including skin, hair, and nails. Severity of psoriasis was assessed using Psoriasis Area and Severity Index into mild, moderate, and severe disease [13]. (c) For laboratory investigations, 5 ml of venous blood was withdrawn from every participant under complete aseptic conditions, transferred into plain tube, and centrifuged at 4000 rpm for 10 min. Serum was obtained for determination of serum hsCRP by ELISA SUN RED ELISA Kit (Shanghai, China) [14]. Serum calcium [15] was evaluated by enzymatic colorimetric technique.

Statistical analysis

Statistical analysis was done using a personal computer with Statistical Package of Social Science (SPSS) SPSS version 20 (IBM Corp., Armonk, NY, USA, version 20 and Epi Info 2000 (Center for Disease Control and Prevention (CDC), Atlanta, Georgia, USA) programs, where the following statistics were applied: mean, SD, range, number, percentage, Student t test, and χ2 test. P value less than 0.05 was considered statistically significant.


  Results Top


This case–control study was conducted on a total number of 80 participants. These included 40 patients with chronic plaque psoriasis. Their age ranged from 18 to 70 years, with mean ± SD of 42.65 ± 14.25 years. There were 18 (45%) males and 22 (55%) females. Their BMI ranged from 22.4 to 26.9, with mean ± SD of 24.90 ± 1.31. Regarding controls, their age ranged from 14 to 66 years, with mean ± SD of 38.00 ± 14.24. There were 15 (37.5%) males and 25 (62.5%) females. Their BMI ranged from 21.9 to 27.2, with mean ± SD of 24.50 ± 1.41. There were no statistically significant differences between patients and controls regarding age, sex, and BMI (P > 0.05% for all).

Clinical criteria of psoriatic patients are demonstrated in [Table 1].
Table 1: Clinical characteristics of patients with psoriasis

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Serum level of calcium in the studied cases ranged from 6.2 to 10.2 mg/dl, with mean ± SD of 8.30 ± 1.30 mg/dl, whereas in the control group, its level ranged from 6.8 to 11.2 mg/dl, with mean ± SD of 9.22 ± 0.82 mg/dl. Comparison of serum calcium levels in patients and controls revealed a statistically significant difference (P < 0.001) [Table 2] and [Figure 1].
Table 2: Serum calcium and high-sensitivity C-reactive protein in studied cases and controls (n=80)

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Figure 1: Comparison between cases and controls regarding serum calcium level (N = 80).

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Serum level of hsCRP in the studied cases ranged from 1.6 to 5.9 mg/dl, with mean ± SD of 4.44 ± 1.11, whereas in the control group, its level ranged from 0.63 to 2.54 mg/dl, with mean ± SD of 1.55 ± 0.64. Comparison of serum hsCRP levels in patients and controls revealed a statistically significant difference (P < 0.001) [Table 2] and [Figure 2].
Figure 2: Comparison between cases and controls regarding serum hsCRP level (N = 80). hsCRP, high-sensitivity C-reactive protein.

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  Discussion Top


Advances in understanding the immune-pathogenesis and genetics of psoriasis have established psoriasis as a chronic, immune-mediated systemic disease associated with significant morbidity and impaired quality of life [16]. Psoriasis is a hyperproliferative skin disease [17]. The skin hyperproliferation in psoriasis is controlled by calcium inside the cells. It also controls the keratinocytes differentiation [18]. There are close relation between psoriasis and serum calcium level. Psoriasis has been found to be aggravated with the decrease in the serum calcium levels. This is because the calcium has an important role in the regulation of keratinocytes. Cell adhesion molecules can be damaged by hypocalcemia [19]. Hypocalcemia results from parathyroidectomy, which leads to psoriasis intensification in patients with psoriasis [20]. Moreover, they may develop typical pustular psoriasis of von Zumbusch owing to hypocalcemia, and as the serum calcium level in the patient improved by giving calcium orally and vitamin D, there was improvement in the psoriasis. However, the psoriasis again was seen as the treatment was discontinued [21]. Kitamura et al. [22] studied cutaneous reactions caused by calcium channel blockers. They concluded that Ca antagonists are occasional causes of a wide spectrum of cutaneous reactions and psoriasiform eruptions. In the current study, serum level of calcium was statistically lower among psoriatic patients compared with controls. This was in agreement with a study by Chaudhari and Rathi [23] on 80 patients with chronic psoriasis of different age and sex and 80 controls. Qadim et al. [24] reported that the prevalence of hypocalcemia was 37.2% in the cases compared with only 9% among the controls in their study, which was conducted on 98 psoriatic patients compared with 100 healthy participants as a control group. In addition, they found that mean serum calcium levels were significantly low in cases compared with controls. They concluded that for psoriasis patients, hypocalcemia was a significant risk factor. Decrease of serum calcium leads to intensifying and extending psoriatic lesion, and accordingly, vitamin D systemic compounds and oral calcium are recommended in treatment [25]. However, Cook and Theirs [18], revealed no abnormalities of calcium metabolism in psoriatic patients and suggested that a systemic aberration of calcium metabolism probably does not occur and that calcium depletion from horny layer may play a role in formation of psoriatic plaque, and significance of its total level is needed to be established. The difference between results of the current study and other studies may be attributed to low sample size and different demographic data.

Patients with psoriasis are at increased risk of CVD, especially those with severe disease at an early age. CRP is an independent risk factor for CVD. The greater than expected incidence of coronary artery disease (CAD) in psoriatic patients might be attributable to the high levels of this marker, and several studies have reported a link between the levels of CRP and CVD, hypertriglyceridemia, abnormal blood pressure, and insulin resistance [26]. In the current study, higher serum hsCRP among cases was statistically significant compared with controls (P < 0.001). These results were in agreement with Ataseven et al. [27], who determined that psoriatic patients had higher levels of hsCRP than controls, and Uysal et al. [28] documented an increase in serum CRP level in psoriatic patients, with more increase in severe cases where tumor necrosis factor α and interleukin-6 contributed toward formation of psoriatic atherosclerotic plaques inducing its release [29]. CRP itself, beyond serving as a biomarker, may be an active inflammatory protein with a role in endothelial cell dysfunction and vascular remodeling [30]. Psoriatic patients already are more prone to CAD and thus raised hsCRP levels make them further more prone for atherosclerotic changes. CRP is an important pathogenic factor for atherosclerosis and induces several reactions involved in atherothrombogenesis. It activates complement and attacks monocytes, incites endothelial dysfunction, augments a procoagulant state, and contributes to plaque instability/rupture [31]. As the level of hsCRP indicates the inflammatory changes occurring at a low level, therefore, if estimated early in the process, it would be beneficial.


  Conclusion Top


Calcium and hsCRP play a role in the pathogenesis of psoriasis. Calcium serum level is lower in psoriatic patients than the normal population, so hypocalcemia is an important risk factor for the development of psoriasis, and oral calcium is recommended in the treatment of psoriasis

HsCRP is a potentially promising inflammatory marker. Its importance in psoriasis is owing to that the inflammatory process, which is shown with the elevation of CRP, contributes toward development of CVD in psoriatic patients. So we can use CRP serum level in the follow-up of the patients and for early detection to cardiovascular complication. Raised hsCRP can be considered as an added risk factor in psoriatic patients with regard to CADs.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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