|Year : 2016 | Volume
| Issue : 1 | Page : 11-17
Quality of life of Egyptian patients with psoriasis: a hospitalbased cross-sectional survey
Amira A Eid1, Heba M Elweshahi2
1 Department of Dermatology, Venereology and Andrology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
2 Department of Community Medicine, Faculty of Medicine, Alexandria University, Alexandria, Egypt
|Date of Submission||25-May-2016|
|Date of Acceptance||27-Jun-2016|
|Date of Web Publication||22-Nov-2016|
Amira A Eid
Department of Dermatology, Venereology and Andrology, Faculty of Medicine, Alexandria University, Elazarita 21521, Alexandria
Source of Support: None, Conflict of Interest: None
Background Quality-of-life (QOL) impairment caused by psoriasis is well documented and is comparable to serious diseases. Several patient-related and disease-related factors can influence the final impact of psoriasis on the QOL.
Aims The aims of this study were to assess the QOL of Egyptian patients with psoriasis and to explore factors affecting the QOL in those patients.
Patients and methods A total of 274 patients (179 male and 95 female) with chronic plaque-type psoriasis were enrolled in the study. Disease severity was assessed using the Psoriasis Area Severity Index (PASI) and patients were asked to answer the Dermatology Life Quality Index (DLQI). DLQI scores and subscores were calculated, and the impact of different patient and disease characteristics on the DLQI was evaluated.
Results The DLQI in patients ranged from 1.0 to 26.0. In 0.7% of the patients, psoriasis exerted no effect on the DLQI, small effect was reported in 10.6% of patients, moderate effect in 28.1% of patients, very large effect in 54% of the patients, and extremely large effect in 6.6% of the patients. A significant direct correlation between the PASI and the DLQI was detected (P<0.001). Both age (r=−0.19, P=0.002) and age at disease onset (r=−0.17, P=0.004) were negatively correlated with the DLQI. Multivariate linear regression analysis revealed the PASI to be an important predictor for QOL impairment in the studied patients.
Conclusion The PASI may be a pivotal factor in determining the final impact of psoriasis on the QOL of Egyptian patients.
Keywords: psoriasis, psoriasis area severity index, quality of life
|How to cite this article:|
Eid AA, Elweshahi HM. Quality of life of Egyptian patients with psoriasis: a hospitalbased cross-sectional survey. Egypt J Dermatol Venerol 2016;36:11-7
|How to cite this URL:|
Eid AA, Elweshahi HM. Quality of life of Egyptian patients with psoriasis: a hospitalbased cross-sectional survey. Egypt J Dermatol Venerol [serial online] 2016 [cited 2020 Jan 26];36:11-7. Available from: http://www.ejdv.eg.net/text.asp?2016/36/1/11/194155
| Introduction|| |
The quality of life (QOL) of patients with skin disorders can be greatly affected by the disfigurement caused by the disease, the impact it has on their daily activities, and by the reaction of others to their disease. A dermatological disorder can affect patients on physical, psychological, social, and occupational levels . Knowing the impact of a certain disease on the patient’s QOL is an important part of overall patient care that may influence the dermatologist’s decisions concerning the treatment plan.
Psoriasis is a chronic relapsing inflammatory skin disease that affects patients of all ages and both sexes, with a mean estimated worldwide prevalence of about 2% . It has a similar prevalence in men and women . The QOL impairment caused by psoriasis is well documented , and is comparable to diseases such as heart disease, diabetes, depression, and even cancer ,. Psoriasis is associated with social stigmatization, discomfort, physical disability, and emotional distress , which have been shown to affect the patients’ QOL. In fact, 80% of patients with psoriasis consider their disease to be a moderate or a large problem in their everyday lives .
The purpose of this study was to assess the QOL impairment in Egyptian patients with psoriasis and to explore factors affecting the QOL in those patients.
| Patients and methods|| |
A hospital-based cross-sectional survey of psoriatic patients attending the dermatology outpatient clinic of a tertiary healthcare facility was conducted over a period of 18 months. All Egyptian patients with moderate, moderate-to-severe, and severe  chronic plaque-type psoriasis attending the clinic of this facility during the period from January 2013 to June 2014 were included in the study, provided they were mentally competent and willing to participate.
Exclusion criteria were as follows: age less than 18 years, mild disease [Psoriasis Area Severity Index (PASI) score<10], and the presence of an associated systemic or dermatologic disease with a known impact on the QOL. Patients with psoriatic arthritis and erythrodermic or pustular psoriasis were also excluded from the study. The study protocol was approved by the local medical ethics committee. An informed consent form was signed by all patients before participation in the study.
At the end of the recruitment phase, 274 patients (179 male and 95 female) were included in the study. They were subjected to history taking and clinical examination. Psoriasis severity was assessed using the PASI . A face-to-face interview using the Arabic version of the Dermatology Life Quality Index (DLQI) questionnaire was conducted  (Arabic translation available at: http://www.dermatology.org.uk/quality/quality-dlqi-languages.html). The DLQI consists of 10 questions that can be grouped under six headings: symptoms and feelings, daily activities, leisure, work and school, personal relationships, and treatment. For each patient, the DLQI score and the individual subscores of the six items of the questionnaire were calculated.
At the end of the recruitment phase data were analyzed. As the total number of male and female patients in the sample was not equal and they differed in their characteristics, comparison between male and female patients as regards QOL and factors affecting it was not possible. A stratified analysis was performed to explore factors affecting the QOL of men, women, and the entire studied sample. Moreover, multivariate linear regression analysis was conducted to identify factors determining the QOL of the studied patients.
Analysis of the data was carried out using IBM SPSS software package (version 20.0.; IBM Corp., Armonk, New York, USA). Qualitative data were described using number and percent. Quantitative data were described using minimum, maximum, mean, and SD. For abnormally distributed data, comparison between two independent populations was made using the Mann–Whitney test. The Kruskal–Wallis test was used when more than two groups were compared and pair-wise comparison was made using the Mann–Whitney test. Correlations between two quantitative variables were assessed using Spearman’s coefficient. The predictive variables for the DLQI in patients were assessed using multivariate linear regression with a 95% confidence interval. When the P value was 0.05 or less, the test result was considered significant.
| Results|| |
Demographic data and clinical characteristics
The study was conducted on 274 patients, 179 (65.33%) male and 95 (34.67%) female. The mean age in the studied patients was 46.46±13.78 years. An overall 83.9% of the patients were married and 50.7% were living in urban areas. At the time of the study, 50% of the patients were employed. The different patient and disease characteristics of the studied patients are outlined in [Table 1].
|Table 1: Different disease and patient variables of the studied patients|
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Dermatology Life Quality Index scores in the studied patients
DLQI scores in the studied patients ranged from 1.0 to 26.0, with a mean of 12.2±5.3. In male patients, the overall DLQI scores ranged from 1.0 to 26.0 (mean±SD=12.06±5.56), whereas in female patients they ranged from 2.0 to 26.0 (mean±SD=12.53±5.01). Details of the DLQI score, subscores, and the interpretation of the overall DLQI scores are outlined in [Table 2].
|Table 2: Dermatology Life Quality Index score, subscores, and interpretation of overall Dermatology Life Quality Index score in the studied patients|
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Effect of age on the Dermatology Life Quality Index
A significant negative correlation between age and the DLQI in psoriatic patients was detected (P=0.002). Age was found to be negatively correlated with symptoms and feelings, daily activities, and treatment subscores (P=0.002, 0.002, and <0.001, respectively). Meanwhile, it was positively correlated with work and school subscore (P=0.006) [Table 3].
|Table 3: Correlation between age, duration, age at onset and the Psoriasis Area Severity Index with different studied parameters in the studied patients|
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In male patients, negative correlations between age and overall DLQI score (P=0.013), daily activities (P=0.008), leisure (P=0.033), and treatment (P<0.001) subscores were detected [Table 2]. Male patients were then divided according to age into three subgroups (<30, 30–60, and >60 years). A significant negative correlation with the DLQI was detected only in patients older than 60 years (r=−0.41, P=0.01), but not in the other two groups. In female patients, age was not correlated with the overall DLQI score, but age was found to be negatively correlated with symptoms and feelings (P<0.001) and daily activities (P=−0.242, P=0.018) and positively correlated with work and school (P=0.006) subscores of the DLQI [Table 3].
Effect of marital status on the Dermatology Life Quality Index
There was no significant difference between married and nonmarried patients as regards the DLQI score or subscores. However, married male patients were found to have significantly lower DLQI scores (P=0.028) compared with nonmarried male patients. Similarly, the symptoms and feelings subscore and leisure subscore were significantly lower in married (P=0.033 and 0.006, respectively) than in nonmarried male patients. However, marital status did not significantly influence the overall DLQI score in female patients (P=0.16), but disease impact on work and school was significantly lower in married female patients (P=0.029).
Effect of area of residence on the Dermatology Life Quality Index
Patients living in urban areas had significantly higher symptoms and feelings subscore (P<0.001) and treatment subscore (P=0.006) compared with patients living in rural areas, but no difference in the overall DLQI score was detected (P=0.166). Male patients living in urban areas had significantly higher DLQI scores (P=0.024) and symptoms and feelings score (P<0.001) than those living in rural areas. However, in female patients, the overall DLQI score was not influenced by the area of residence, but the impact of disease on work and school was significantly higher in those living in rural areas (P=0.006), and the impact of treatment item was significantly higher in those living in urban areas (P<0.001).
Effect of occupational status on the Dermatology Life Quality Index
Occupational status had no impact on the overall DLQI score of the studied patients, but employed patients had significantly lower symptoms and feeling (P=0.003) and personal relationship (P=0.001) subscores compared with unemployed patients or housewives. Employed male patients had significantly lower symptoms and feelings (P=0.035) and personal relationships subscores (P=0.013) and significantly higher daily activity subscores (P=0.034) compared with unemployed and retired male patients. Among female patients, unemployed patients had significantly higher symptoms and feelings subscore compared with housewives and employed patients (P=0.014).
Effect of age at disease onset on the Dermatology Life Quality Index
In the studied patients, age at disease onset was negatively correlated with the overall DLQI score, symptoms and feelings, daily activities, personal relationships, and treatment subscores (P=0.004, 0.001, 0.005, 0.019, and 0.001, respectively). Meanwhile, it was positively correlated with work and school subscore (P=0.007). Age at disease onset showed a significant negative correlation with DLQI scores (P=0.007), daily activities (P=0.015), leisure (P=0.021), and treatment (P<0.001) subscores of the DLQI in male patients. However, in female patients, a significant negative correlation with symptoms and feelings (P<0.001) and daily activities (P=0.023), and a significant positive correlation with work and school (P<0.001) subscores of the DLQI were detected [Table 3].
Effect of disease duration on the Dermatology Life Quality Index
The mean disease duration in the studied patients was 9.1±6.8 years. Disease duration did not show any significant correlation with the overall DLQI score or the individual subscores in the studied patients. Mean disease duration in male patients was 8.67±7.24 years, and in female patients it was 9.92±5.99 years. Disease duration showed a significant positive correlation (P=0.036) and a significant negative correlation (P<0.001) with work and school subscore in male and female patients, respectively [Table 3].
Effect of Psoriasis Area Severity Index score on the Dermatology Life Quality Index
In the studied patients, PASI scores ranged from 10.10 to 48.50. A significant positive correlation between PASI and the overall DLQI score, symptoms and feelings, daily activities, and leisure subscores in the studied patients was detected (P<0.001, 0.001, <0.001, and 0.001, respectively). Both male and female patients showed significant positive correlations between PASI scores and the overall DLQI score, symptoms and feelings, and leisure subscores. In addition, a significant positive correlation with daily activities subscore in the male group was detected [Table 3].
Several models of multivariate linear regression analysis were used to identify factors affecting the overall DLQI scores and its subscores. The PASI was the only significant predictor of the overall DLQI score (F=10.163, P<0.001) and R2=0.10 denotes that the PASI accounts for 10% of variation in the total DLQI score [Table 4]. Furthermore, the PASI was the only predictive variable for daily activities (P<0.001) and leisure (P=0.001) subscores in the studied patients. Sex was only a predictive variable for work and school subscore (P<0.001), with male patients having a higher disease impact on work and school compared with female patients. The area of residence (P<0.001) and age of the patient (P<0.001) were predictive variables for the treatment subscore, wherein living in urban areas and younger age seemed to be associated with greater impact of the treatment subscore on the QOL impairment. Higher PASI, living in urban areas, unemployment, and younger age were predictors for higher impact on the symptoms and feelings subscore (P<0.001, <0.001, 0.013, and 0.028, respectively). Occupational status was the only predictor for the personal relationship subscore of the DLQI, wherein employed patients had lower disease impact on personal relationships.
|Table 4: Linear regression of factors affecting the Dermatology Life Quality Index in the studied patients|
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| Discussion|| |
Psoriasis is notorious for its negative impact on the QOL. This impact is substantial and is even more with severe disease, or when the disease extends beyond the skin to involve the joints . In addition to interfering with sexual functioning and occupational productivity, psoriasis can disrupt the daily lives of the patients, thus representing a psychological and a financial burden to the patients ,.
Several factors can influence the final impact of psoriasis on the QOL. Gelfand et al.  found the extent of skin involvement to be the most important factor related to the QOL impairment in psoriatic patients. However, Lee et al.  reported less QOL impairment in patients with longer disease durations; hence, they considered disease duration to be the most important factor related to QOL. Furthermore, lack of correlation between the PASI and the DLQI was reported in patients with long disease durations ; accordingly, it was suggested that longer disease durations are possibly associated with the development of coping and adaptive mechanisms in patients, ultimately leading to less disease impact on their QOL. However, Fortune et al.  did not find disease duration to be associated with any of the QOL indices. Similarly, in the present study, no correlation between disease duration and QOL impairment was detected, suggesting that the final impact on the QOL cannot be attributed to just one factor, but rather to the interplay of several factors.
Although studies addressing the influence of sex on the impact of psoriasis on the QOL yielded variable results , a stronger impact of psoriasis on the QOL is generally detected in female patients compared with male patients ,. Psoriasis was reported to be associated with lower psychosocial morbidity in male patients , and female patients were repeatedly reported to have higher overall mean DLQI scores compared with male patients ,. This has been explained by the fact that female patients tend to be more concerned with their body image and their appearance; hence, diseases that affect patients’ appearance will have higher impact on the QOL of female patients as compared with male patients . Nevertheless, in a study on Chilean patients, men had significantly higher overall mean DLQI scores compared with female patients, a finding that was attributed to the greater disease extent in male patients in the studied sample . Some authors, however, found that sex did not influence QOL impairment in psoriatic patients ,. In the present study, regression analysis revealed sex to be a predictive variable only for work and school item of the DLQI, with male patients scoring higher on that item compared with female patients. The difference between male and female patients as regards work could be explained by the fact that most of the female patients in the present study were housewives, who unlike their male counterparts, did not have to deal with work-related stresses. This is in accordance with the findings of Gupta and Gupta , who reported higher work-related stress in male patients compared with female patients.
Women living in rural areas in the present study had higher disease impact on the work and school subscore compared with those living in urban areas, which could be attributed to the fact that in rural areas the housewives’ chores require more physical effort and more outdoor activities. However, patients living in urban areas were associated with higher disease impact on symptoms and feelings item of the DLQI. Indeed, in the present study, the area of residence was a predictor for the symptoms and feelings subscore. This could be explained by the more demanding nature of life in urban areas.
Being already settled in their lives, married patients are less likely to experience rejection because of their skin condition. In nonmarried patients, development of a chronic disease may in fact influence the patient’s decision with regard to marriage . Married patients were previously reported to have less QOL impairment compared with nonmarried patients . Although the QOL impairment detected in the present study was lower in married than in nonmarried patients, the difference was not significant. Furthermore, marital status was not found to be a predictor for the DLQI or any of its items, suggesting a minimal influence of marital status on QOL impairment in the studied patients, which could be ascribed to population differences in the way patients react to diseases.
In the present study, younger ages and a lower age at disease onset were associated with higher DLQI scores. This is in accordance with the findings of previous studies, which reported greater QOL impairment  and greater psychological impact of psoriasis in younger patients . Old age was also reported to be associated with lower QOL impairment in psoriatic patients , and older age at psoriasis onset was associated with lower psychosocial morbidity . The impact of psoriasis on the QOL was reported to be greater in younger patients (18–45 years) . In addition, the QOL impairment in psoriatic patients was reported to decrease with increasing age . In contrast to the previous findings, Mørk et al.  reported a higher impact of psoriasis on the QOL in older patients. Furthermore, Sampogna et al.  detected greater DLQI scores in female patients older than 65 years, but not in male patients. The inverse relation between age or age at disease onset and the disease impact on the QOL detected in the present study could be explained by the fact that old age is usually associated with several chronic diseases, which might influence the reaction of the patient to the existing psoriatic condition. In addition, 60 is the age of retirement; accordingly, patients have less workload and less work-related stress by that age, which could provide a plausible explanation for the detected inverse correlation with age. Furthermore, the present study reported lower disease impact on symptoms and feeling and daily activities in association with older age, which might suggest that older patients may be more capable of coping with the stigmatization and psychosocial comorbidities associated with the disease compared with younger patients.
Regardless of the tool used to assess the impact of psoriasis on the QOL, several authors reported lack of correlation between disease severity and disease impact on the QOL of patients ,,. Findings of the present study, however, revealed a direct correlation between the PASI and the DLQI in the studied patients. This is in accordance with the findings of Mørk et al. , who detected a significant relation between the PASI and the DLQI, wherein higher PASI scores were associated with higher impact on QOL. In fact, reduction in PASI scores after treatment was reported to be associated with a significant decline in the DLQI of the patients when compared with the pretreatment values . In addition, in the present study, a direct relation between PASI score and symptoms and feelings and impact of treatment subscales of the DLQI in psoriatic patients was detected . Not only did the present study detect a direct correlation between the PASI and the DLQI but it also revealed the PASI to be an important predictive variable for QOL impairment in patients.
| Conclusion and recommendations|| |
It is assumed that the interplay of several patient-related, disease-related, and population-related factors determines the final impact of a given disease on the QOL. However, findings of the present study suggest that the PASI plays a major role in determining the impact of psoriasis on the QOL of the patients. Further multicenter, case–control studies including both the private and governmental sectors are therefore recommended.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Rani Z, Khan MS, Aman S, Nadeem M, Hameed A, Kazmi AH. Quality of life issues and new benchmarks in the assessment of skin diseases. J Pak Assoc Dermatol 2005; 15:339–344.
Christophers E. Psoriasis − epidemiology and clinical spectrum. Clin Exp Dermatol 2001; 26:314–320.
Raychaudhuri SP, Farber EM. The prevalence of psoriasis in the world. J Eur Acad Dermatol Venereol 2001; 15:16–17.
Dubertret L, Mrowietz U, Ranki A, van de Kerkhof PC, Chimenti S, Lotti T, Schäfer G EUROPSO Patient Survey Group. European patient perspectives on the impact of psoriasis: the EUROPSO patient membership survey. Br J Dermatol 2006; 155:729–736.
Hong J, Koo B, Koo J. The psychosocial and occupational impact of chronic skin disease. Dermatol Ther 2008; 21:54–59.
Rapp SR, Feldman SR, Exum ML, Fleischer AB Jr, Reboussin DM. Psoriasis causes as much disability as other major medical diseases. J Am Acad Dermatol 1999; 41(Pt 1):401–407.
Choi J, Koo JY. Quality of life issues in psoriasis. J Am Acad Dermatol 2003; 49(Suppl):S57–S61.
Fortune DG, Richards HL, Griffiths CE. Psychologic factors in psoriasis: consequences, mechanisms, and interventions. Dermatol Clin 2005; 23:681–694.
Daudén E, Conejo J, García-Calvo C. Physician and patient perception of disease severity, quality of life, and treatment satisfaction in psoriasis: an observational study in Spain. Actas Dermosifiliogr 2011; 102:270–276.
Naldi L. Scoring and monitoring the severity of psoriasis. What is the preferred method? What is the ideal method? Is PASI passé? Facts and controversies. Clin Dermatol 2010; 28:67–72.
Fredriksson T, Pettersson U. Severe psoriasis − oral therapy with a new retinoid. Dermatologica 1978; 157:238–244.
Finlay AY, Khan GK. Dermatology Life Quality Index (DLQI) − a simple practical measure for routine clinical use. Clin Exp Dermatol 1994; 19:210–216.
Schmid-Ott G, Schallmayer S, Calliess IT. Quality of life in patients with psoriasis and psoriasis arthritis with a special focus on stigmatization experience. Clin Dermatol 2007; 25:547–554.
Finlay AY, Coles EC. The effect of severe psoriasis on the quality of life of 369 patients. Br J Dermatol 1995; 132:236–244.
Krueger G, Koo J, Lebwohl M, Menter A, Stern RS, Rolstad T. The impact of psoriasis on quality of life: results of a 1998 National Psoriasis Foundation patient-membership survey. Arch Dermatol 2001; 137:280–284.
Gelfand JM, Feldman SR, Stern RS, Thomas J, Rolstad T, Margolis DJ. Determinants of quality of life in patients with psoriasis: a study from the US population. J Am Acad Dermatol 2004; 51:704–708.
Lee YW, Park EJ, Kwon IH, Kim KH, Kim KJ. Impact of psoriasis on quality of life: relationship between clinical response to therapy and change in health-related quality of life. Ann Dermatol 2010; 22:389–396.
Silva MF, Fortes MR, Miot LD, Marques SA. Psoriasis: correlation between severity index (PASI) and quality of life index (DLQI) in patients assessed before and after systemic treatment. An Bras Dermatol 2013; 88:760–763.
Fortune DG, Main CJ, O’Sullivan TM, Griffiths CE. Quality of life in patients with psoriasis: the contribution of clinical variables and psoriasis-specific stress. Br J Dermatol 1997; 137:755–760.
Schmid-Ott G, Künsebeck HW, Jäger B, Sittig U, Hofste N, Ott R et al.
Significance of the stigmatization experience of psoriasis patients: a 1-year follow-up of the illness and its psychosocial consequences in men and women. Acta Derm Venereol 2005; 85:27–32.
McKenna KE, Stern RS. The impact of psoriasis on the quality of life of patients from the 16-center PUVA follow-up cohort. J Am Acad Dermatol 1997; 36(Pt 1):388–394.
Ginsburg IH, Link BG. Feelings of stigmatization in patients with psoriasis. J Am Acad Dermatol 1989; 20:53–63.
Mørk C, Wahl A, Moum T. The Norwegian version of the dermatology life quality index: a study of validity and reliability in psoriatics. Acta Derm Venereol 2002; 82:347–351.
Sampogna F, Chren MM, Melchi CF, Pasquini P, Tabolli S, Abeni D. Age, gender, quality of life and psychological distress in patients hospitalized with psoriasis. Br J Dermatol 2006; 154:325–331.
Stowers DA, Durm MW. Does self-concept depend on body image? A gender analysis. Psychol Rep 1996; 78:643–646.
Valenzuela F, Silva P, Valdés MP, Papp K. Epidemiology and quality of life of patients with psoriasis in Chile. Actas Dermosifiliogr 2011; 102:810–816.
Lundberg L, Johannesson M, Silverdahl M, Hermansson C, Lindberg M. Health-related quality of life in patients with psoriasis and atopic dermatitis measured with SF-36, DLQI and a subjective measure of disease activity. Acta Derm Venereol 2000; 80:430–434.
Gupta MA, Gupta AK. Age and gender differences in the impact of psoriasis on quality of life. Int J Dermatol 1995; 34:700–703.
Bhatti Z, Salek M, Finlay A. Chronic diseases influence major life changing decisions: a new domain in quality of life research. J R Soc Med 2011; 104:241–250.
Zachariae R, Zachariae H, Blomqvist K, Davidsson S, Molin L, Mørk C, Sigurgeirsson B. Quality of life in 6497 Nordic patients with psoriasis. Br J Dermatol 2002; 146:1006–1016.
Fernandez-Peñas P, Jones-Caballero M, Espallardo O, García-Díez A. Comparison of Skindex-29, Dermatology Life Quality Index, Psoriasis Disability Index and Medical Outcome Study Short Form 36 in patients with mild to severe psoriasis. Br J Dermatol 2012; 166:884–887.
[Table 1], [Table 2], [Table 3], [Table 4]