A Questionnaire Based Study on the Concepts of Protein Supplementation in Exfoliative Dermatitis Among Dermatologists

Introduction: The impact of exfoliative dermatitis on protein metabolism results in a negative nitrogen balance, but the exact turnover of plasma proteins in this situation is not known. Timely addressing of this metabolic response to exfoliation is crucial in its management. Objectives: To study the understanding on the concept of protein supplementation in cases of exfoliative dermatitis, among dermatologists. Material and methods: A cross sectional questionnaire based survey study was conducted among dermatologists who attended annual state conference of IADVL, Kerala chapter. Analysis was based on responses to the questionnaire by 51 practicing dermatologists who had answered and returned the questionnaire, out of the total 84 who were approached for the study. Responses to questions from the interviews were summarized and expressed as numbers and percentages. Results: Majority (32, 62.7%) of the dermatologists attributes chronicity of illness to the severity of protein loss in exfoliative dermatitis. Though serum albumin level is considered as the criterion for protein supplementation, opinion regarding the frequency of estimation, mode and end point of supplementation varies. The majority (36, 70.6%) of dermatologists regards protein supplementation as mandatory in all cases of exfoliative dermatitis and that it helps in recovery of the condition, irrespective of etiology. Limitation: The small sample size is an obvious limitation Conclusion: Lack of a clear consensus and knowledge regarding the turnover of plasma proteins in exfoliative dermatitis and the correction of hypoalbuminemia, is clearly portrayed by our results. Further studies are needed to explore the exact pathophysiology of metabolic response to exfoliation and to fill the gaps in the understanding of the same.


Introduction
E xfolia ve derma s or erythroderma, fi rst described by Von Hebra in 1868, is an infl ammatory disorder of skin characterized by generalized redness and scaling of skin involving more than 90% of the body surface area.Even with an es mated annual incidence of 35 cases per 1,00,000 dermatology outpa ent visits represen ng 1-1.5% of total skin clinic admissions [1][2][3][4] , the exact e ology and overall ma nagement of exfolia ve derma s o en stands challenging.There exists a number of gaps in the understanding of the metabolic eff ects of exfolia ve derma s and its correc on.
The metabolic response to exfolia on and its eff ect on nitrogen balance was studied with great enthusiasm in the past.It was observed that pa ents with exfolia ve derma s develop the s gmata of nega ve nitrogen balance-edema, hypoalbuminemia, and loss of muscle mass. 5The disturbance in protein metabolism in exfolia ve derma s usually occurs due to protein lost from the skin and gastrointes nal tract, due to malabsorp on, increased catabolism, decreased synthesis and decreased intake of protein.According to the study by Freedberg and Baden, exfolia on more than 17 g/m 2 /day can lead to a nega ve nitrogen balance. 3Later, Kanthraj et al observed that exfolia ve derma s may increase the daily protein loss by approximately 25-30% in psoriasis and by 10-15% in exfolia ve derma s due to other causes.Based on this observa on, they recommend early supplementa on of protein, in addi on to the normal balanced diet, for minimizing the nega ve nitrogen balance. 4e concepts of protein supplementa on and monitoring, and the relevance given to the same varies among prac oners.In our daily clinical prac ce we come across the situa on of hypoalbuminemia in exfolia ve derma s, but the severity of hypoalbuminemia and its response to protein supplementa on varies.The primary e ology, chronicity of illness and inter individual varia ons may be the key players in such situa on, but the exact turnover of proteins in exfolia ve derma s is far from known.Also, the tally of mortality caused due to these metabolic complica ons calls for the unmet need for a standardiza on in the monitoring of protein levels and mode of its supplementa on in cases of exfolia ve derma s.This is our pioneer venture to study the understanding regarding the concepts of protein supplementa on in exfolia ve derma s among dermatologists of Kerala.We hope that this may pave way to future research in these not so frequently pondered areas.

Material and methods
This was a cross sec onal ques onnaire based survey study conducted among prac cing dermatologists of Kerala, India, conducted at the venue of annual conference of IADVL Kerala chapter, held on 9 th and 10 th of May 2015, in agreement with local regula ons.A structured ques onnaire on protein loss and supplementa on in cases of exfolia ve derma s was distributed among the dermatologists who a ended the conference.

Statistical analysis
The responses to various ques ons were tabulated and sta s cal analysis was done using SPSS 17.0 so ware.Responses to ques ons from the interviews were summarized and expressed as numbers and percentages.

Concepts on gravity of protein loss
Majority of dermatologists (32, 62.7%) considers that amount of protein lost in cases of exfolia ve derma s is related to the chronicity of illness, whereas 10 (19.6%) a ributes it to the primary e ology and the rest 8 (15.7%) prac oners regards that both e ology and chronicity contributes to the severity of protein loss.(Figure 1) Exfolia ve derma s secondary to psoriasis was reported to have the most severe protein loss by the majority (35, 68.6%), but for few (8, 15.7%) exfolia ve derma s secondary to internal malignancy had the maximum protein loss.Other e ologies men oned where atopic derma s, contact derma s and use of ayurvedic medicines.

Concepts on monitoring of protein levels
Serum albumin level is considered as the criterion for determining the amount of protein to be supplemented by 34(66.7%)dermatologists and the majority(37, 72.5%) es mates serum albumin levels in cases of exfolia ve derma s.But for 11(21.56%)dermatologists amount to be supplemented is fi xed in all cases and 6(11.7%)considers that clinical severity determines the amount of protein to be supplemented.(Figure2) Among the 14(27.5%)dermatologists who does not regularly es mate serum albumin levels, 6(42.8%) were not aware of its importance, 4(28.57%)considers it not important to es mate albumin, as they plan to supplement anyway and 1 (7.1%) considers it not cost eff ec ve to monitor serum albumin levels.Another 3 dermatologists had le the ques on unanswered.
The frequency of es ma on of serum albumin levels varies in the study popula on, majority(16, 43.2%) monitors serum albumin level every 2 weeks,11 (29.7.5%) of them does the es ma on every 4 weeks.Monitoring of serum albumin level is done weekly and every 3 weeks by 5(13.5%)each.(Figure 3)
Regarding the dura on of protein supplementa on, majority (23,45.1%)gives supplementa on ll there is documented normal serum albumin level, 9(17.6%) of them considers arrest of exfolia ve derma s as end point for supplementa on, 5(9.8%) of them considers both, 6(11.7%)stops supplementa on at some arbitrary me and the rest states various reasons like clinical improvement, when scales and edema decreases or when pa ent is assessed as clinically stable.
The majority (36, 70.6%) of dermatologists regards protein supplementa on as mandatory in all cases of exfolia ve derma s and 33(64.7%) of them observed that protein supplementa on will help in recovery of the condi on, irrespec ve of the e ology.But there are a few who disagrees this argument.(Table 1)

Discussion
The relevance given to metabolic response to exfolia on varies among dermatologists.Though most of the prac oners consider that protein supplementa on is mandatory and prac ces so based on serum albumin level es ma on, 25.5% does not consider it mandatory.Interes ngly, 27.5% agreed that serum albumin levels are not es mated regularly due to either lack of awareness or importance or as it is not cost eff ec ve.The frequency of es ma on of serum albumin levels also varies widely, but majority considers biweekly es ma on as ideal.We have observed hesitancy for parenteral supplementa on among some dermatologists (23.5%), even when serum albumin levels are less than 2g/dl.There exists a diff erence in opinion also regarding the end point of protein supplementa on.
The concepts regarding various aspects of protein supplementa on in exfolia ve derma s varies widely among dermatologists.This might be due to our oversight of importance of protein supplementa on, lack of awareness or due to the s ll unfi lled gaps in turnover of proteins.Though the management of protein supplementa on in exfolia ve derma s is o en argued to be individualized, a further research in this aspect will help in be er pa ent care.The small sample size is an obvious limita on of our study.But the alarming varia on in concepts, points to the fact that this popula on may be considered to speak for the unrepresented lots.

Conclusion
Irrespec ve of primary e ology, monitoring of serum albumin levels and protein supplementa on are held with importance by majority of the dermatologists.But, the lack of a defi nite protocol or awareness is evidently portrayed by our results.The utmost need for a concensus statement and guidelines for the overall management of metabolic disturbance in exfolia ve derma s is clearly established from the results of our study.Hence, unfolding the mystery of exact pathophysiology of protein metabolism and turnover of plasma protein proteins in exfolia ve derma s is the need of the hour.

Figure 1 :Table 1 :Figure 3 :
Figure 1: Distribu on of study popula on based on their concepts on determinants of amount protein loss in cases of exfolia ve derma s

Figure 2 :
Figure 2: Percentage distribu on of the study popula on based on the factor determining protein supplementa on in cases of exfolia ve derma s