الفهرس 
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Abstract
Psoriasis is a chronic autoimmune, inflammatory, and proliferative disfiguring disease with multi-systemic affection. It manifests as inflammatory erythematous plaques covered by silvery white scales, particularly over the extensor surfaces, scalp, and lumbosacral region. Psoriasis may also affect the joints and increase the risk of developing cardiovascular diseases, metabolic syndrome, Crohn’s disease, ulcerative colitis, and uveitis.
Psoriasis affects about 125 million people worldwide. It is more prevalent in adults than children, affecting both males and females equally. The hallmark of the pathogenesis of psoriasis is sustained inflammation, which leads to uncontrolled keratinocyte proliferation and dysfunctional differentiation. The main risk factors that are attributed to the pathogenesis of psoriasis are genetic risk factors and environmental risk factors such as infection, stress, or traumatic insult. Also, gut and skin dysbiosis have been found to be linked to the pathogenesis of psoriasis.
The main lines of treatment for psoriasis are topical steroids, vitamin D analogs, dithranol, and tar preparations as the first line. The second line of treatment involves phototherapy (narrowband ultraviolet B radiation (NB-UVB), psoralen, and ultraviolet A radiation (PUVA)) and standard systemic non-biological drugs (Methotrexate, Ciclosporin, and Acitretin). The third line of treatment is used for severe and systemic diseases. It includes systemic biological drugs such as tumor necrosis factor inhibitors (Adalimumab, Etanercept, and Infliximab), interleukin (IL)-17 inhibitors and IL-23 inhibitors, Ustekinumab that affects interleukin-12 (IL-12) and IL-23, and small molecule inhibitors such as dimethyl fumarate and Apremilast therapies.
Management of psoriasis can be a frustrating experience for both doctors and patients because of its chronic, flaring, and disfiguring nature. So, besides the mainstay treatment, many therapeutic modalities have been tried for this condition. One of them is probiotic administration, which has gained attention as a potential treatment that can improve the clinical course of psoriasis.
Probiotics are living microorganisms that can positively influence the assortment of gut microbiota by introducing certain beneficial microorganisms to the gastrointestinal tract, resolving dysbiosis, which can further modulate the performance of the immune system, thus providing cost-effective management for the treatment of many diseases such as psoriasis, ulcerative colitis, necrotizing enterocolitis, and type 2 diabetes.
This meta-analysis aimed to assess the evidence of probiotics effectiveness in psoriasis treatment.
The literature was reviewed till December 2022 and yielded 15,875 articles and 6 registries; then 5,160 duplicates were removed. Out of 10,715 screened abstracts, we excluded 10,715. Thus, 19 full-text studies were assessed for eligibility, and 11 were excluded. Finally, eight studies were included for further qualitative and quantitative analyses.
The results showed that probiotics resulted in a significant improvement of PASI 50 and PASI 75 among patients who received probiotics in comparison with the control group (RR = 2.4, 95% CI = 1.26 to 4.74, P = 0.008) and (RR = 1.89, 95% CI = 1.5 to 2.3, P value <0.001), respectively.
Probiotics resulted in a significant improvement of the DLQI score after 4 weeks, 8 weeks, and 12 weeks of the intake of probiotics in the intervention group compared to the control group (SMD = -1.06, 95% CI = -1.6 to -0.5, P = 0.0001), (SMD = -0.5, 95% CI = -0.856 to -0.180, P = 0.003), and (SMD = 2.4, 95% CI = 2 to 2.7, P <0.0001), respectively.
Regarding the effect of probiotics on the inflammatory markers, our results showed that there was a significant reduction in the CRP level, IL1-β level, and LPS level in the probiotic group compared to the control group (SMD = -1.1, 95% CI = 1.943 to -0.316, P <0.001), (SMD = -1.77, 95% CI = -3.52 to -0.8, P = 0.043), and (SMD = -7.47, 95% CI = -13.52 to -1.20, P = 0.01), respectively. However, probiotics did not exert a significant effect on serum levels of IL-6, IL-7, IL-23, or TNF-α.
Regarding the effect of probiotics on the serum level of trace elements, our results showed that there was a significant improvement in the serum levels of calcium, phosphorous, and zinc in the probiotic group compared to the placebo group (SMD = -0.7, 95% CI = -1.1 to -0.3, P = 0.001), (SMD = -0.3, 95% CI = -0.58 to -0.016, P = 0.04), and (SMD = -14.4, 95% CI = -25.3 to -3.6, P = 0.01), respectively. However, probiotics did not exert a significant effect on serum levels of iron, potassium, sodium, and copper.
In comparison with the control group, probiotics did not show a significant result regarding the rate of relapse and the incidence of gastrointestinal adverse effects.
It was concluded that probiotics caused a significant clinical improvement among psoriasis patients as compared with standard care or placebo in terms of the PASI score, DLQI score, CRP level, IL-1β level, LPS level, calcium level, phosphorous level, and zinc level. This beneficial effect could play a role in the management of psoriasis and could contribute to a better clinical course for these patients.
It is recommended to consider probiotics as a potentially beneficial drug for psoriasis to improve its clinical course. Also, we recommend more studies to nullify or empathize with the present study results.