Effect of Psoriasis on Quality of Life

Introduction: Psoriasis is one of the common skin disorders which has a significant distressing effects on patients due to its chronicity, joint involvement, therapy related side effects and its impact on physical appearance. Objective: To find out impairment in quality of life among patients with psoriasis. Materials and Methods: Patients attending the Dermatology outpatient department of Gandaki Medical College were recruited for the study from December 2016 to July 2017. Dermatology Life Quality Index (DLQI) was used to assess the psychosocial involvement. Results: Significant increase in DLQI scores depicting graver psychosocial involvement in females compared to males was observed (p=0.038). Comparison between severity of disease and DLQI scores showed a positive correlation but was not statistically significant (r=0.22 & p=0.187). When we compared the type of psoriasis with severity of disease, chronic plaque psoriasis showed significant statistical correlation (p=0.003). Conclusion: Females tend to experience significant impairment in quality of life compared to males. Further studies with more sample size are needed to consolidate or rectify our findings.


Introduction
P soriasis is a chronic infl ammatory dermatosis that aff ects around 125 million people worldwide. 1sually it does not aff ect survival but has signifi cant harmful eff ects on quality of life (QOL). 2Psoriasis has a bimodal age distribu on, which peaks in the 20s and 60s. 3 It is o en linked with social impairment, decreased self-confi dence, pain, physical disability, and psychological distress. 46][7] Many factors may be a ributed to the decreased QOL in pa ents, especially the chronic relapsing nature of the disease, lack of control and fear of disease breakout, and hopelessness in terms of cure. 8Psoriasis has a strong socioeconomic impact on pa ents' lives; thus, it is essen al to fi nd out pa ent's goals and make a prac cal and realis c treatment plan.This includes both general measures and specifi c treatment, including counseling, rest, and advice on moisturizing the skin round-the-clock, which may be signifi cant in improving the QOL of the pa ents.

Materials and Methods
Pa ents more than 18 years a ending the outpa ents department of Dermatology of Gandaki Medical College were selected from December 2016 to July 2017.Prior permission was taken from the ins tu onal review board.Informed consent was taken from all pa ents enrolled in the study.Proforma of all the pa ents were fi lled out.For all the pa ents, Dermatology Quality Life Index (DLQI) was used to Licensed under CC BY 4.0 International License which permits use, distribution and reproduction in any medium, provided the original work is properly cited.http://dx.doi.org/10.3126/njdvl.v16i1.19407access the psychosocial involvement.We divided the pa ents into mild (<3% BSA), moderate (3-10% BSA) and severe (>10 %BSA) based only on the area of skin involvement.In this study Body Surface Area (BSA) index was used for assessing the severity of psoriasis.Contrary to Psoriasis Area and Severity Index (PASI), BSA does not include erythema, infi ltra on, and desquama on.We focused on the severity of disease according to the BSA and did not include detailed clinical fi ndings of psoriasis. [11][12]

Results
All analysis were done using sta s cal package for social sciences (SPSS).Univariate or Bivariate analysis was done using t-tests wherever appropriate, p value less than 0.05 was considered sta s cally signifi cant.The total number of par cipants were 36 (23 males and 13 females).Mean age of the pa ents was 31.64±10.22yrs, youngest pa ent being 19 years and the eldest was of 52 years.Out of 36 pa ents only 4 had severe disease, 12 had mild disease and remaining 20 had moderate disease.Two pa ents had very large psychosocial involvement (DLQI Score 11-20), 20 pa ents had small eff ect, four had moderate eff ect and 10 pa ents had no psychosocial involvement at all.Relevant data are given in Table 1.
Bivariate correla on between DLQI scores and body surf4ace area (BSA) showed a posi ve correla on but was not sta s cally signifi cant (r=0.22 & p=0.187).Independent sample t-Test showed signifi cant increase in DLQI scores in females compared to males (p value 0.038) (Table 2).
There was no signifi cant correla on between the type of Psoriasis and DLQI scores but when we compared the type of psoriasis with severity of disease, chronic plaque psoriasis had a higher mean BSA of 5.26% compared to 2.56% in other types resul ng in signifi cant sta s cal correla on (p=0.003).

Discussion
The most important aspect in the management of psoriasis is counseling.The clinician has to be considerate, he should have ample pa ence and counsel the pa ent regarding nature of the disease; its non-contagious nature; its remi ng and relapsing  course; the factors which lead to its relapse such as stress, both physical and mental, drugs, and alcohol; and how to cope with the disease and carry out rou ne ac vi es. 13 Pa ents should be very well informed about the therapeu c op ons available and the poten al side eff ects.Control of the disease should be the primary objec ve rather than cure of the disease. 14mo onal stress may play an important role in the development and exacerba on of psoriasis in 37-78% of pa ents. 15Since many skin disorders are commonly associated with social s gma za on, pa ents can suff er from frustra on, anxiety, or depression.7] Dalgard FJ et al found that pa ents with psoriasis were more prone to have psychological eff ects than those with other skin condi ons. 18jtyna E et al found the impact of physical appearance in personal life and its blemishes having signifi cant associa on with risk for depression. 19Awareness of the pa ent, and the reac ons of others, may play an important role in psychosocial stability.In comparison to other skin condi ons psoriasis has more nega ve psychosocial impact on the pa ents.Misconcep on of infec ous and contagious nature of psoriasis is very common. 20Kurd SK et al showed that the adjusted hazard ra o (HR) of depression was higher in severe (1.72; 95% CI, 1.57-1.88)compared with mild psoriasis (1.38; 95% CI, 1.35-1.40).The adjusted hazard ra o of suicidal thoughts was higher in pa ents with severe psoriasis (1.51, 95% CI, 0.92, 2.49) compared to mild psoriasis. 213] Muta ons in genes associated with psoriasis which increase proinfl ammatory cytokines can lead to HPA axis over ac vity and disturbance of nega ve feedback inhibi on of circula ng cor costeroids.This in turn can lead to lower serotonergic levels and depressive symptoms. 24 Mood disorders, par cularly depression, have been suggested to be more in pa ents with psoriasis than in the general popula on (up to 62% prevalence).In a meta-analysis of 98 cross-sec onal studies examining the associa on between psoriasis and depression, pa ents with psoriasis had more depressive symptoms (pooled standardized mean diff erence, 1.16 [95% CI, 0.67-1.66])and were nearly 1.6-fold more likely to experience depression (pooled OR, 1.57 [95% CI, 1.40-1.76])than pa ents without psoriasis. 27e risk of depression in psoriasis has been evaluated in two cohort studies.In a study from UK, psoriasis was found to be associated with increased risk of depression (HR, 1.39 [95%CI, 1.37-1.41]),anxiety (HR, 1.31 [95% CI, 1.29-1.34]),and suicidality (HR, 1.44 [95% CI, 1.32-1.57]). 28Among pa ents who were receiving therapies for severe psoriasis the risk of depression was the most (HR, 1.72 [95% CI, 1.57-1.88]).Similarly, a study of women in the Nurses' Health Study found psoriasis to be associated with a nearly 30% increased risk of depression (RR, 1.29 [95% CI, 1.10-1.52]),independent of age. 29

Conclusion
Our study showed that females had signifi cant impairment of quality of life compared to males.Chronic plaque psoriasis was posi vely associated with severity of disease than other types of psoriasis.Further studies with more sample size are needed to consolidate or rec fy our fi ndings.

Financial disclosure:
None.Confl icts of interest to disclosure: None declared.

Table 2 :
DLQI scores in males and females.
DLQI-Dermatology Life Quality Index, SD-Standard devia on