Ko Shu-Hua, Chi Ching-Chi, Yeh Mei-Ling, Wang Shu-Hui, Tsai Yu-Shiun, Hsu Mei-Ya
Department of Nursing, Wei-Gong Memorial Hospital, 128, Shin-I Rd, Toufen, Miaoli, Taiwan, 35159.
Cochrane Database Syst Rev. 2019 Jul 16;7(7):CD011972. doi: 10.1002/14651858.CD011972.pub2.
Psoriasis is an inflammatory skin disease that presents with itching, red, scaling plaques; its worsening has been associated with obesity, drinking, smoking, lack of sleep, and a sedentary lifestyle. Lifestyle changes may improve psoriasis.
To assess the effects of lifestyle changes for psoriasis, including weight reduction, alcohol abstinence, smoking cessation, dietary modification, exercise, and other lifestyle change interventions.
We searched the following databases up to July 2018: the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We also searched the China National Knowledge Infrastructure, the Airiti Library, and five trials registers up to July 2018. We checked the references of included trials for further relevant trials, and we asked the authors of the included trials if they were aware of any relevant unpublished data.
We included randomised controlled trials (RCTs) of lifestyle changes (either alone or in combination) for treating psoriasis in people diagnosed by a healthcare professional. Treatment had to be given for at least 12 weeks. Eligible comparisons were no lifestyle changes or another active intervention.
We used standard methodological procedures expected by Cochrane. The primary outcome measures were 'Severity of psoriasis' and 'Adherence to the intervention'. Secondary outcomes were 'Quality of life', 'Time to relapse', and 'Reduction in comorbidities'. We used GRADE to assess the quality of the evidence for each outcome.
We included 10 RCTs with 1163 participants (mean age: 43 to 61 years; 656 men and 478 women were reported). Six trials examined the effects of dietary intervention (low-calorie diet) in 499 obese participants (mean age: 44.3 to 61 years; where reported, 395 had moderate-to-severe psoriasis). One trial assessed a combined dietary intervention and exercise programme in 303 obese participants with moderate-to-severe psoriasis who had started a systemic therapy for psoriasis and had not achieved clearance after four weeks of continuous treatment (median age: 53 years). Another trial assessed a walking exercise and continuous health education in 200 participants (mean age: 43.1 years, severity not reported). Finally, two trials included education programmes promoting a healthy lifestyle in 161 participants (aged 18 to 78 years), with one trial on mild psoriasis and the other trial not reporting severity.Comparisons included information only; no intervention; medical therapy alone; and usual care (such as continuing healthy eating).All trials were conducted in hospitals and treated participants for between 12 weeks and three years. One trial did not report the treatment period. Seven trials measured the outcomes at the end of treatment and there was no additional follow-up. In two trials, there was follow-up after the treatment ended. Five trials had a high risk of performance bias, and four trials had a high risk of attrition bias.We found no trials assessing interventions for alcohol abstinence or smoking cessation. No trials assessed time to relapse. Only two trials assessed adverse events; in one trial these were caused by the add-on therapy ciclosporin (given in both groups). The trial comparing two dietary interventions to a no-treatment group observed no adverse events.The results presented in this abstract are based on trials of obese participants.Outcomes for dietary interventions versus usual care were measured 24 weeks to six months from baseline. Compared to usual care, dietary intervention (strict caloric restriction) may lead to 75% or greater improvement from baseline in the Psoriasis Area and Severity Index (PASI 75) (risk ratio (RR) 1.66, 95% confidence interval (CI) 1.07 to 2.58; 2 trials, 323 participants; low-quality evidence). Adherence to the intervention may be greater with the dietary intervention than usual care, but the 95% CI indicates that the dietary intervention might also make little or no difference (RR 1.26, 95% CI 0.76 to 2.09; 2 trials, 105 participants; low-quality evidence). Dietary intervention probably achieves a greater improvement in dermatology quality-of-life index (DLQI) score compared to usual care (MD -12.20, 95% CI -13.92 to -10.48; 1 trial, 36 participants; moderate-quality evidence), and probably reduces the BMI compared to usual care (MD -4.65, 95% CI -5.93 to -3.36; 2 trials, 78 participants; moderate-quality evidence).Outcomes for dietary interventions plus exercise programme were measured 16 weeks from baseline and are based on one trial (303 participants). Compared to information only (on reducing weight to improve psoriasis), combined dietary intervention and exercise programme (dietetic plan and physical activities) probably improves psoriasis severity, but the 95% CI indicates that the intervention might make little or no difference (PASI 75: RR 1.28, 95% CI 0.83 to 1.98). This combined intervention probably results in a greater reduction in BMI (median change -1.10 kg/m², P = 0.002), but there is probably no difference in adherence (RR 0.95, 95% CI 0.89 to 1.01; 137/151 and 145/152 participants adhered in the treatment and control group, respectively). There were no data on quality of life. These outcomes are based on moderate-quality evidence.
AUTHORS' CONCLUSIONS: Dietary intervention may reduce the severity of psoriasis (low-quality evidence) and probably improves quality of life and reduces BMI (moderate-quality evidence) in obese people when compared with usual care, while combined dietary intervention and exercise programme probably improves psoriasis severity and BMI when compared with information only (moderate-quality evidence). None of the trials measured quality of life.We did not detect a clear difference in treatment adherence between those in the combined dietary intervention and exercise programme group and those given information only (moderate-quality evidence). Adherence may be improved through dietary intervention compared with usual care (low-quality evidence). Participants generally adhered well to the lifestyle interventions assessed in the review.No trials assessed the time to relapse. Trial limitations included unblinded participants and high dropout rate.Future trials should reduce dropouts and include comprehensive outcome measures; they should examine whether dietary intervention with or without an exercise programme is effective in non-obese people with psoriasis, whether an additional exercise programme is more effective than dietary intervention alone, whether the time to relapse prolongs in people who receive dietary intervention with or without exercise programme, and whether smoking cessation and alcohol abstinence are effective in treating psoriasis.
银屑病是一种炎症性皮肤病，表现为瘙痒、红色鳞屑斑块；其病情加重与肥胖、饮酒、吸烟、睡眠不足及久坐的生活方式有关。生活方式的改变可能改善银屑病。
评估生活方式改变对银屑病的影响，包括减重、戒酒、戒烟、饮食调整、运动及其他生活方式改变干预措施。
截至2018年7月，我们检索了以下数据库：Cochrane皮肤专业注册库、CENTRAL、MEDLINE、Embase和LILACS。我们还检索了中国知网、华艺数位图书馆以及截至2018年7月的五个试验注册库。我们检查了纳入试验的参考文献以寻找更多相关试验，并询问纳入试验的作者是否知晓任何相关未发表的数据。
我们纳入了针对经医疗专业人员诊断为银屑病的患者进行生活方式改变（单独或联合）治疗的随机对照试验（RCT）。治疗必须持续至少12周。合格的对照为不进行生活方式改变或另一种积极干预措施。
我们采用Cochrane期望的标准方法程序。主要结局指标为“银屑病严重程度”和“干预措施依从性”。次要结局为“生活质量”“复发时间”和“合并症减少情况”。我们使用GRADE评估每个结局的证据质量。
我们纳入了10项RCT，共1163名参与者（平均年龄：43至61岁；报告的男性656名，女性478名）。6项试验研究了饮食干预（低热量饮食）对499名肥胖参与者（平均年龄：44.3至61岁；报告中，395名患有中度至重度银屑病）的影响。1项试验评估了饮食干预与运动计划相结合对303名患有中度至重度银屑病且已开始接受银屑病系统治疗但连续治疗四周后未清除皮损的肥胖参与者（中位年龄：53岁）的效果。另一项试验评估了步行运动和持续健康教育对200名参与者（平均年龄：43.1岁，严重程度未报告）的影响。最后，两项试验纳入了针对161名参与者（年龄18至78岁）的促进健康生活方式的教育计划试验，一项试验针对轻度银屑病患者，另一项试验未报告严重程度。比较组包括仅提供信息；不进行干预；仅药物治疗；以及常规护理（如持续健康饮食）。所有试验均在医院进行，对参与者的治疗时间为12周至三年。一项试验未报告治疗期。7项试验在治疗结束时测量结局，且未进行额外随访。两项试验在治疗结束后进行了随访。5项试验存在实施偏倚的高风险，4项试验存在失访偏倚的高风险。我们未发现评估戒酒或戒烟干预措施的试验。没有试验评估复发时间。仅有两项试验评估了不良事件；在一项试验中，不良事件由附加治疗环孢素（两组均使用）引起。比较两种饮食干预与未治疗组的试验未观察到不良事件。本摘要中的结果基于肥胖参与者的试验。饮食干预与常规护理相比的结局在基线后24周至六个月进行测量。与常规护理相比，饮食干预（严格热量限制）可能使银屑病面积和严重程度指数（PASI 75）较基线改善75%或更多（风险比（RR）1.66，95%置信区间（CI）1.07至2.58；2项试验，323名参与者；低质量证据）。饮食干预的干预措施依从性可能高于常规护理，但95%CI表明饮食干预也可能几乎没有差异或无差异（RR 1.26，95%CI 0.76至2.09；2项试验，105名参与者；低质量证据）。与常规护理相比，饮食干预可能在皮肤病生活质量指数（DLQI）评分上有更大改善（MD -12.20，95%CI -13.92至-10.48；1项试验，36名参与者；中等质量证据），且与常规护理相比可能降低BMI（MD -4.65，95%CI -5.93至-3.36；2项试验，78名参与者；中等质量证据）。饮食干预加运动计划的结局在基线后16周进行测量，基于一项试验（303名参与者）。与仅提供信息（关于减重以改善银屑病）相比，饮食干预与运动计划相结合（饮食计划和体育活动）可能改善银屑病严重程度，但95%CI表明该干预可能几乎没有差异或无差异（PASI 75：RR 1.28，95%CI 0.83至1.98）。这种联合干预可能导致更大程度的BMI降低（中位变化-1.10 kg/m²，P = 0.002），但在依从性方面可能没有差异（RR 0.95，95%CI 0.89至1.01；治疗组和对照组分别有137/151和145/152名参与者依从）。没有生活质量数据。这些结局基于中等质量证据。
与常规护理相比，饮食干预可能降低肥胖人群银屑病的严重程度（低质量证据），可能改善生活质量并降低BMI（中等质量证据），而饮食干预与运动计划相结合与仅提供信息相比可能改善银屑病严重程度和BMI（中等质量证据）。没有试验测量生活质量。我们未发现饮食干预与运动计划相结合组和仅提供信息组在治疗依从性上有明显差异（中等质量证据）。与常规护理相比，饮食干预可能提高依从性（低质量证据）。参与者总体上对综述中评估的生活方式干预措施依从性良好。没有试验评估复发时间。试验的局限性包括参与者未设盲和高失访率。未来的试验应减少失访并纳入全面的结局测量；应研究饮食干预加或不加运动计划对非肥胖银屑病患者是否有效，额外的运动计划是否比单独的饮食干预更有效，接受饮食干预加或不加运动计划的人群复发时间是否延长，以及戒烟和戒酒对治疗银屑病是否有效。
