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Helicobacter pylori infection and skin diseases

Author: Dr Eugene Tan, Dermatology Registrar, Waikato Hospital, Hamilton, New Zealand, 2009.


Helicobacter pylori infection and skin diseases — codes and concepts
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What are Helicobacter pylori?

Helicobacter pylori (H. pylori) are bacteria found in the stomach that are responsible for most cases of peptic ulcer. About half of the world's population has the bacteria making it the most common bacterial infection in humans [1].

H. pylori infection is more common in developing nations. The risk of contracting H. pylori is related to socioeconomic status and poor living conditions such as overcrowding, lack of clean, running water and a higher number of siblings. As a result, most children in developing nations are infected before the age of 10.

In New Zealand, there is a higher prevalence amongst Maori and Polynesians. Studies show that about 5% of European children become infected with H. pylori by the age of 20 years, in contrast to 50% of Polynesian children [2].

The exact route of infection remains unknown, but person-to-person transmission through oral/oral or faecal/oral exposure is the most likely cause. Activities such as sharing food, cutlery or poor toilet hygiene can result in the transmission of H. pylori to another individual.

What diseases are linked to H. pylori infection?

H. pylori cause direct disease of the stomach. Other conditions are probably related to the body's immune response to the bacteria.

  • Chronic gastritis (inflammation of the stomach lining)
  • Peptic ulcers
  • Stomach cancers
  • Certain types of lymphomas (cancers of lymphoid tissue)

What are the symptoms of H. pylori infection?

Most individuals with H. pylori infection have no symptoms. Symptoms arise if infection with H. pylori causes peptic ulcers or gastritis. These symptoms can be non-specific and may include:

  • Abdominal pain (usually in the upper abdomen)
  • Nausea
  • Vomiting
  • Bloating
  • Red or tar-coloured stools (indicating bleeding in the intestine)
  • Low blood count (anaemia).

How do H. pylori damage the stomach?

The damage to the lining of the stomach is due to a complex interaction of the bacteria and the host's immune response. H. pylori release several enzymes and microbial products that directly damage the lining of the stomach. The immune system reacts by mounting a florid inflammatory response in an attempt to eradicate the bacteria. As a consequence of this inflammatory response, the stomach lining is unintentionally damaged.

What investigations are there for H. pylori?

There are several tests available to detect the presence of H. pylori in the stomach:

  • Blood test – This detects specific antibodies against H. pylori bacterium.
  • Breath test – This involves drinking a solution of carbon labelled urea. This solution is broken down by H. pylori, and its breakdown products can be detected in the breath.
  • Stool test – This detects H. pylori proteins in the faeces.
  • Endoscopic testing – This involves the use of optical instruments for the visual examination of interior parts of the body. A flexible tube is inserted through the mouth into the stomach and upper regions of the small intestine. Small tissue samples can be taken from the stomach wall, which is then tested for H. pylori.

Blood test and breath test are often the first line approach to testing for H. pylori. Endoscopic biopsy is a relatively invasive procedure and is often reserved for patients who require endoscopy for another reason.

Who should be tested?

The American College of Gastroenterology recommends testing in the following situations [3]:

  • Patients with active peptic ulcer disease
  • A history of documented peptic ulcer
  • Gastric MALT (Mucosa Associated Lymphoid Tissue) lymphoma
  • Patients who have undergone resection of early gastric cancer.

Testing is not recommended for people who are asymptomatic (no symptoms) or who have no history of peptic ulcer disease. However, certain population groups who are at risk for developing ulcers or stomach cancers may be considered for asymptomatic testing.

What is the treatment?

Treatment of H. pylori infection involves taking several medications for 7 to 14 days (“Triple therapy”), for example, a proton-pump inhibitor (inhibitor of stomach acid secretion) such as omeprazole 40mg once daily, amoxicillin 1g twice daily and clarithromycin 500mg twice daily.

Treatment cures up to 90% of individuals.

What is the relationship of H. pylori to diseases of the skin?

H. pylori have been implicated in a variety of diseases that are not related to the gastrointestinal tract. The skin is an example, and several studies have suggested an association with the following conditions [4,5]:

Does the treatment of H. pylori affect skin disease?

Several small studies have suggested that eradicating H. pylori has a positive outcome on certain skin diseases such as urticaria, Behçet diseaselichen planusatopic dermatitisSweet disease and systemic sclerosis. Conditions which may not benefit are psoriasis and rosacea.

These studies are not randomised and involve small numbers of patients so no definitive conclusion can be drawn about the eradication of H. pylori in skin diseases at present.

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References

  1. Cover TL, Blaser MJ. Helicobacter pylori in health and disease. Gastroenterology 2009; 136: 1863-73. Medline.
  2. Fraser A. Helicobacter pylori: a historical perspective 1983-2003. N Z Med J 2004; 117: 1194. U896. Fulltext.
  3. Chey WD, Wong BC. American College of Gastroenterology guideline on the management of Helicobacter pylori infection. Am J Gastroenterol 2007; 102: 1808-25. Medline.
  4. Hernando-Harder AC, Booken N, Goerdt S et al. Helicobacter pylori infection and dermatologic diseases. Eur J Dermatol 2009. Medline.
  5. Wedi B, Kapp A. Helicobacter pylori infection in skin diseases: a critical appraisal. Am J Clin Dermatol 2002; 3: 273-82. Medline.

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