From the Guidelines
DISH (Diffuse Idiopathic Skeletal Hyperostosis) is a condition that may be associated with long-term treatment with certain medications, such as etretinate and isotretinoin, and is characterized by abnormal bone growth along the spine and other areas where ligaments and tendons attach to bone. According to the British Association of Dermatologists guidelines on the efficacy and use of acitretin in dermatology 1, the effects of acitretin on the skeletal system are rare, but possible similarities to etretinate suggest that long-term treatment may be associated with DISH-like involvement.
Key Considerations
- The condition is more prevalent in older adults, particularly men over 50, and is associated with metabolic factors like type 2 diabetes and obesity.
- Treatment focuses on symptom management rather than curing the condition, and may include pain relief with acetaminophen or NSAIDs, physical therapy to maintain mobility and strengthen supporting muscles, and weight management.
- Routine radiography has no place in the monitoring of acitretin therapy and is potentially harmful, unless musculoskeletal pain is atypical, in which case targeted investigation with X-rays may be recommended 1.
Management
- For pain relief, options may include acetaminophen (500-1000mg every 6 hours as needed) or NSAIDs like ibuprofen (400-800mg three times daily with food) or naproxen (220-500mg twice daily).
- Physical therapy is recommended to maintain mobility and strengthen supporting muscles.
- Weight management is important as excess weight can worsen symptoms.
- For severe cases, corticosteroid injections may provide temporary relief, and surgery may be considered if there's significant nerve compression or difficulty swallowing due to cervical spine involvement.
From the Research
Definition and Characteristics of DISH
- Diffuse idiopathic skeletal hyperostosis (DISH) is a systemic condition characterized by the ossification and calcification of ligaments and entheses 2.
- It is observed on all continents and in all races, but most commonly in men over 50 years of age 2.
- DISH is often asymptomatic, but can lead to symptoms including pain, stiffness, reduced range of articular motion, and dysphagia 2, 3.
Clinical Presentation and Diagnosis
- The condition can cause respiratory manifestations, such as airway obstruction, due to cervical osteophytes protrusion 4.
- Dysphagic symptoms are more frequent, but DISH may also be a cause of airway obstruction and should be included in the differential diagnosis of respiratory distress and OSA 4.
- Radiographically, DISH is characterized by flowing ossifications along the anterior spine spanning ≥4 vertebral bodies 3.
- The presence of at least three bony bridges at the anterolateral spine is a characteristic feature of DISH 5.
Pathogenesis and Associated Factors
- The pathogenesis of DISH is currently unknown, but it has been associated with older age, male sex, obesity, hypertension, atherosclerosis, and diabetes mellitus 2, 5.
- Local fibroblasts, chondrocytes, collagen fibers, and calcified matrix are probably influenced by genetic, vascular, metabolic, and mechanical factors 5.
- The condition is also associated with an increased risk of unstable spinal fractures, metabolic syndrome, coronary and aortic disease, and respiratory effects 2, 3, 5.
Management and Treatment
- Treatment should be aimed at symptomatic relief of pain and stiffness, prevention of progression, and treatment of associated metabolic disorders 6.
- Change of lifestyle, nutrition, and therapeutic options to alleviate pain and stiffness are measures that might improve quality of life in patients affected by DISH 6.
- Control of associated metabolic disorders, such as hypertension, hyperinsulinaemia, and hyperlipidaemia, may reduce the morbidities associated with these disorders and prevent further progression of the condition 6.