Psoriasis

By Marcello Cherchi, MD PhD

For patients

Patients with psoriasis usually have problems with their skin, such as scaly skin and plaques. Patients with psoriatic arthritis also have joint pain. Some of these psoriasis patients also notice problems with their hearing (such as hearing loss and tinnitus) and balance. In that situation your doctor may check several tests of hearing and balance, and may refer you to an audiologist or vestibular physical therapist. Psoriasis should still be managed by a dermatologist, and psoriatic arthritis should still be managed by a rheumatologist.

For clinicians

Overview

Psoriasis and psoriatic arthritis are common multisystem autoimmune diseases that typically manifest with skin lesions (and in the case of psoriatic arthritis, with joint abnormalities and arthralgias). Some of these patients also complain of auditory symptoms (hearing loss, tinnitus) and vestibular symptoms (disequilibrium). It appears that, independently of any other diseases, patients with psoriasis and psoriatic arthritis can develop hearing loss and abnormalities on vestibular tests — specifically on cervical vestibular evoked myogenic potentials (cVEMP), saccades, caloric testing and computerized dynamic posturography (CDP). In these patients it is reasonable to undertake a screening audiovestibular workup to assess for more common causes of these symptoms, but if no other diseases are found, then it is reasonable to ascribe the findings to the psoriasis or psoriatic arthritis alone. Patients with hearing loss and/or tinnitus should be referred to audiology. Patients with vestibular weakness should consider a trial of vestibular rehabilitation therapy (VRT). These patients should continue the broader management of their disease under the supervision of their dermatologist and/or rheumatologist.

Introduction

Psoriasis and psoriatic arthritis are common multisystem autoimmune diseases that typically manifest with skin lesions (and in the case of psoriatic arthritis, with joint abnormalities and arthralgias). Some of these patients also complain of auditory symptoms (hearing loss, tinnitus) and vestibular symptoms (disequilibrium).

Epidemiology

Estimates of worldwide prevalence of psoriasis range from 0.51% to 11.43% in adults, and 0% to 1.37% in children (Michalek et al. 2017). Psoriasis affects males and females approximately equally, and is more common in geographic regions more distant from the equator (Parisi et al. 2013). In the United States it is more common among Caucasians, followed by African-Americans, followed by Hispanics (Rachakonda et al. 2014).

Genetics

Several genome-wide association studies (Ellinghaus et al. 2010; Genetic Analysis of Psoriasis et al. 2010; Huffmeier et al. 2010; Mahil et al. 2015; Nair et al. 2009; Stuart et al. 2010; Tsoi et al. 2012) have identified dozens of genes that appear to confer susceptibility to developing psoriasis.

Pathophysiological mechanism of disease

Ertugrul and colleagues (Ertugrul et al. 2020) summarize that:

“Psoriasis is a chronic inflammatory disease that may present as erythematosus, squamous plaques or pustular lesions in the body. The exact etiology is not clear. However, the autoimmune mechanism characterized by T cell-mediated hyperproliferation of keratinocytes has been implicated in the etiology” (Ertugrul et al. 2020).

The mechanism by which this T cell-mediated autoimmune process might affect auditory and/or vestibular function is unknown.

Clinical presentation

Dermatologic manifestations are usually what bring patients to the attention of medical professionals. However, these patients also have auditory and vestibular complaints more frequently than controls.

Studies report similar rates of auditory symptoms (hearing loss, tinnitus) and vestibular symptoms (“vertigo,” “dizziness,” “disequilibrium”) in patients with psoriasis (Temel et al. 2017) and psoriatic arthritis (Amor-Dorado et al. 2014). The data from these studies are juxtaposed in Table 1.

	Psoriasis (Temel et al. 2017)			Psoriatic arthritis (Amor-Dorado et al. 2014)
	Patients (n=60)	Controls (n=60)	p	Patients (n=61)	Controls (n=61)	p
Hearing loss	28 (46%)	5 (8%)	0.001	19 (32%)	4 (7%)	0.001
Tinnitus	18 (30%)	3 (5%)	0.001	17 (28%)	2 (3%)	<0.001
Vertigo	19 (31%)	2 (3%)	0.001	12 (20%)	0 (0%)	<0.001
Dizziness	12 (20%)	2 (3%)	0.005	15 (25%)	1 (2%)	<0.001
Disequilibrium	17 (28%)	2 (3%)	0.001	17 (28%)	0 (0%)	<0.001

Table : Frequency of audio-vestibular symptoms in patients with psoriasis and psoriatic arthritis.

Physical examination

The dermatologic manifestations of psoriasis include “glossy skin or pearly white scales on the extensor surface of the body and the scalp, with limited erythematous plaques or papillae” (Kınar et al. 2022).

Ocular motor examination

As of this writing, no published studies described face-to-face ocular motor examinations in patients with psoriasis or psoriatic arthritis.

Testing: auditory

Ger and colleagues (Ger et al. 2023) conducted a systematic review and meta-analysis of 15 studies (12 case-control/cross-sectional and 3 cohort studies) and concluded that:

“We found significant differences between psoriasis patients and healthy controls in the PTA thresholds. We also found 3.85-fold increased odds for SNHL and 1.45-fold increased risk for SSNHL among psoriasis patients when compared with nonpsoriatic controls. Hearing thresholds in PTA showed significant differences across all frequencies from 500 Hz to 6000 Hz in psoriasis patients when compared with the control group. We found that the higher the PTA frequency, the greater the severity of hearing loss” (Ger et al. 2023).

Testing: vestibular

Kinar and colleagues (Kınar et al. 2022) studied 43 psoriasis patients and 40 healthy controls, and reported statistically significantly lower cervical vestibular evoked myogenic potentials (cVEMP) amplitudes in the psoriasis patients.

Siag and colleagues (Siag et al. 2024) studied 33 psoriasis patients and 30 healthy controls using video head impulse testing (vHIT). They concluded that “the number of patients with right anterior semicircular canal gain value outside the normal range was significantly higher in the psoriasis group compared to the control group,” though oddly, the actual data presented in the paper do not show any statistically significant difference between patients and controls in any canal.

Temel and colleagues (Temel et al. 2017) studied electronystagmography in 61 psoriasis patients and 61 controls. They reported statistically significantly greater occurrence of “saccadic abnormalities” in patients than in controls. No statistically significant difference between the two groups was found in other ocular motor tests (spontaneous nystagmus, gaze-evoked nystagmus, positional nystagmus, Dix-Hallpike test, caloric test, smooth pursuit, optokinetic responses).

Ertugrul and colleagues (Ertugrul et al. 2020) studied 32 patients with psoriasis (without arthritis) and 35 healthy controls. They reported that 9 (28%) of the psoriasis patients exhibited caloric abnormalities, whereas none of the healthy controls did. Of the nine psoriatic patients with caloric abnormalities, right-sided weakness was identified in 3, left-sided in two, and bilateral in four.

Amor-Dorado and colleagues (Amor-Dorado et al. 2014) studied videonystagmography (VNG) in 60 patients with psoriatic arthritis and 60 healthy controls. They reported that 16 (27%) of the psoriatic arthritis patients exhibited caloric abnormalities, whereas none of the healthy controls did. A subsequent study by the same group reported similar results (Amor-Dorado et al. 2017). A meta-analysis of 13 studies (including 589 patients) also reported that caloric testing was abnormal in psoriasis patients statistically significantly more than controls (Jeong et al. 2022).

Amor-Dorado and colleagues (Amor-Dorado et al. 2014) studied computerized dynamic posturography (CDP) in 60 patients with psoriatic arthritis and 60 healthy controls. They reported that 14 (23%) of the psoriatic arthritis patients of the psoriatic arthritis patients exhibited abnormal CDP (usually in a vestibular pattern), whereas none of the healthy controls did. A subsequent study by the same group reported similar results (Amor-Dorado et al. 2017).

Imaging

Brain imaging does not play a role in confirming/excluding whether psoriasis or psoriatic arthritis is the mechanism of auditory or vestibular complaints. Imaging may help identify alternative diagnoses.

Histopathology

There are no published temporal bone studies from patients with psoriasis or psoriatic arthritis who had audiologic or vestibular complaints.

Differential diagnosis

It is rare for an otoneurologist or neuro-otologist to be the first medical practitioner to suspect psoriasis or psoriatic arthritis. The more common scenario is that in which a patient with an established diagnosis (of psoriasis or psoriatic arthritis) is referred to otoneurology or neuro-otology for evaluation of audiologic or vestibular symptoms.

In such cases the otoneurologist or neuro-otologist is usually tasked with figuring out whether the patient has some other disease (unrelated to psoriasis or psoriatic arthritis) that might account for the audiologic or vestibular complaints, and whether that other disease warrants specific treatment. To this end, it is reasonable to undertake a screening audio-vestibular workup, with a selection of instrumented tests based on the clinical presentation.

In a patient with auditory symptoms it is medically reasonable to check audiometry, otoacoustic emissions (OAE), and perhaps auditory brainstem evoked responses (ABR). In a patient with vestibular symptoms it is medically reasonable to check cervical vestibular evoked myogenic potentials (cVEMP), ocular vestibular evoked myogenic potentials (oVEMP), video head impulse testing (vHIT), videonystagmography (VNG) and computerized dynamic posturography (CDP). If the vestibular complaints include chronic disequilibrium, then rotatory chair testing (RCT) may also be appropriate.

If no evidence for an alternative diagnosis is found, then it is reasonable to conclude that the auditory and/or vestibular symptom is a manifestation of psoriasis or psoriatic arthritis alone.

Management

If a patient with psoriasis or psoriatic arthritis complains of hearing loss or tinnitus, or is found to have hearing loss on testing, it is reasonable to consult with audiology regarding amplification and/or tinnitus masking.

If a patient with psoriasis or psoriatic arthritis complains of disequilibrium, and if workup reveals evidence of vestibular weakness (either unilateral or bilateral), then referral to vestibular rehabilitation therapy (VRT) is reasonable.

The patient should continue the management of the psoriasis or psoriatic arthritis itself under the supervision of their dermatologist and/or rheumatologist.

Prognosis

There are no studies regarding the prognosis specifically of audiologic or vestibular symptoms in patients with psoriasis or psoriatic arthritis.

References

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Amor-Dorado JC, Barreira-Fernandez MP, Pina T, Vázquez-Rodríguez TR, Llorca J, González-Gay MA (2014) Investigations into audiovestibular manifestations in patients with psoriatic arthritis. J Rheumatol 41: 2018-26. doi: 10.3899/jrheum.140559

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