The skin and bone, though seemingly distinct, share intricate biological connections. Emerging evidence suggests that chronic dermatological conditions can adversely affect skeletal health through multiple pathways, including systemic inflammation, altered vitamin D metabolism, and medication-induced bone loss. [1-3]

Chronic inflammatory skin diseases such as psoriasis, atopic dermatitis, and systemic sclerosis are associated with elevated pro-inflammatory cytokines (e.g., TNF-α, IL-6, IL-17), which accelerate bone resorption by activating osteoclasts. [4] Psoriasis, in particular, has been linked to a higher prevalence of osteoporosis and fractures, independent of traditional risk factors. [5] The persistent inflammatory state disrupts the RANKL/OPG (Receptor Activator of Nuclear Factor Kappa-B Ligand/Osteoprotegerin) axis, leading to unbalanced bone remodeling. [6]

Vitamin D, synthesized in the skin upon UV exposure, plays a pivotal role in calcium homeostasis and bone mineralization. Dermatological conditions that limit sun exposure (e.g., photodermatoses, severe eczema) or impair vitamin D synthesis (e.g., vitiligo) contribute to hypovitaminosis D, exacerbating bone fragility. [7] Furthermore, long-term use of corticosteroids—a mainstay in treating severe skin diseases—induces osteoporosis by suppressing osteoblast activity and increasing osteoclastogenesis. [8]

Biologic therapies, such as anti-TNF-α agents, may have dual effects: while reducing inflammation, they might also influence bone turnover. [9] However, conflicting data exist regarding their long-term impact on fracture risk. [10-13]

This study represents the relationship between dermatological conditions and bone health, focusing on mechanisms, clinical outcomes, and management strategies.

This was a cross-sectional observational study conducted at a tertiary care hospital over a period of 1 year. Ethical approval was obtained from the institutional ethics committee, and informed consent was taken from all participants.

Inclusion Criteria

• Adults aged 18–65 years
• Diagnosed with a chronic dermatological condition (duration >6 months)
• Diagnoses included: psoriasis, atopic dermatitis, systemic lupus erythematosus (SLE), and systemic sclerosis
• Willingness to undergo bone mineral density (BMD) testing

Exclusion Criteria

• History of diagnosed osteoporosis or metabolic bone diseases
• Patients on antiresorptive therapy (e.g., bisphosphonates)
• Chronic kidney disease, liver disease, or endocrine disorders affecting calcium metabolism
• Long-term (>6 months) corticosteroid use for non-dermatological conditions
• Pregnant or lactating women
• Alcohol dependence or substance abuse

Data Collection

Participants were evaluated through clinical examination, detailed history, and lab investigations. The severity of skin disease was assessed using standard scoring tools:

• Psoriasis Area and Severity Index (PASI)
• Eczema Area and Severity Index (EASI)
• Modified Rodnan skin score (for systemic sclerosis)

BMD was measured at the lumbar spine and femoral neck using dual-energy X-ray absorptiometry (DEXA). Osteopenia and osteoporosis were classified as per WHO criteria.

Biochemical Analysis

Blood samples were collected to evaluate:

• Serum calcium, phosphorus, vitamin D, and parathyroid hormone (PTH)
• Inflammatory markers: TNF-α, IL-6, IL-17
• ESR and CRP levels

Statistical Analysis

Data were analyzed using SPSS v26. Continuous variables were expressed as mean ± SD, and categorical variables as percentages. ANOVA and Chi-square tests were used for comparisons. Multivariate regression was applied to identify predictors of low BMD.

Table 1: Demographic Profile of Study Participants

In table 1, the mean age of participants ranged from 35.6 to 45.2 years across disease groups. The psoriasis and systemic sclerosis groups had a higher proportion of males, whereas atopic dermatitis (AD) and systemic lupus erythematosus (SLE) groups were predominantly female.

Table 2: Bone Mineral Density (BMD) Scores

Table 3: Prevalence of Osteopenia and Osteoporosis

In table 3, Systemic sclerosis patients showed the highest prevalence of both osteopenia (50%) and osteoporosis (30%), followed by SLE and psoriasis. In contrast, only 10% and 2% of controls had osteopenia and osteoporosis, respectively.

Table 4: Inflammatory Markers

Table 5: Vitamin D Status

In table 5, Vitamin D deficiency was notably more common in patients with skin diseases, particularly SLE (60%) and AD (50%), compared to controls (20%).

Table 6: Predictors of Low BMD (Multivariate Regression)

His study confirms a statistically significant association between dermatological conditions—particularly those with systemic inflammatory components—and reduced bone mineral density. Psoriasis, SLE, and systemic sclerosis exhibited the greatest impact on skeletal health. The elevated inflammatory cytokine levels, notably TNF-α and IL-6, likely contribute to increased osteoclast activity and bone resorption, echoing findings from previous research. [14,15]

Vitamin D deficiency was another prominent finding among patients with chronic skin conditions. Reduced sun exposure due to lifestyle changes and photophobia in these individuals may account for this trend. [16] Vitamin D not only plays a pivotal role in calcium absorption but also modulates immune responses, potentially affecting the course of skin inflammation. [17]

Corticosteroid therapy remains a double-edged sword. While effective in managing skin symptoms, long-term use—even in topical form—can impair osteoblast function and promote bone loss. [18] Interestingly, even in patients not on corticosteroids, low BMD was prevalent, underscoring the role of systemic inflammation as an independent risk factor. [19]

This research aligns with prior studies highlighting similar trends. A cohort study by Cohen et al. found that psoriasis patients had a 1.7-fold increased risk of osteoporosis compared to controls^20^. Similarly, systemic sclerosis has been linked with reduced physical activity and malabsorption, further compounding bone loss. [20,21]

The implications of these findings are far-reaching. Dermatologists should consider routine BMD screening in patients with chronic, severe skin diseases. Interdisciplinary approaches involving nutritionists, rheumatologists, and endocrinologists are vital. Lifestyle interventions, such as encouraging weight-bearing exercise, ensuring adequate vitamin D and calcium intake, and minimizing unnecessary corticosteroid use, should be integral to patient management plans. [22]

Limitations of this study include its cross-sectional design and relatively small sample size. Longitudinal studies would better clarify causality and the long-term impact of skin diseases on skeletal health. Furthermore, quantifying physical activity levels and incorporating bone turnover markers would provide a more comprehensive picture.

Overall, the results affirm the need for greater awareness of the systemic effects of dermatological conditions, particularly in regard to skeletal integrity. Proactive management and early detection could significantly reduce the risk of fractures and improve quality of life.

Chronic dermatological conditions, particularly those associated with systemic inflammation such as psoriasis, SLE, and systemic sclerosis, are linked with reduced bone mineral density and higher rates of osteopenia and osteoporosis. Elevated inflammatory markers and vitamin D deficiency play significant roles. An integrated, multidisciplinary approach that includes bone health monitoring is essential in the long-term management of these patients.

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