Assessment of Quality of Life in a Sample of Iraqi Patients with Psoriasis

The State Company for Marketing Drugs and Medical Appliances, Ministry of Health and Environment, Baghdad, Iraq. Department of Clinical Pharmacy, College of Pharmacy, University of Baghdad, Baghdad, Iraq. Center of Dermatology and Venereology, Medical City, Baghdad, Iraq. Abstract Psoriasis is a dermatological, chronic, immune-mediated condition. Psoriasis symptoms are not associated with physical burden only, but it may also have psychosocial effects on patients, diminished cognitive control, poor body image and impairments in everyday life. The value of quality of life is important since improving it is the principal goal for non-curative disease. The aim of the current study was to evaluate quality of life in a sample of Iraqi patients with psoriasis. This study is a cross-sectional study that involved 300 already diagnosed psoriasis patients who attended to the center of Dermatology and Venereology, Medical City/Baghdad. The mean age of patients was (35.156 ±10.549 years). The Arabic version of Dermatology Life Quality Index was used to assess quality of life. The mean total score is 11.29± 5.45 and the majority of the patients (53.7%) had a total score of more than 10, which indicates a significant deterioration in patients’ quality of life. The greatest impact was found in symptoms and feelings (mean = 1.66 ± 0.75) while the lowest impact was noted in personal relationships (0.51± 0.65). Increasing age and monthly income as well as vulgaris type of psoriasis associated significantly better quality of life. While Psoriasis Area and Severity Index associated significantly worse quality of life. In conclusion, psoriasis exerts significant, negative impact on patients’ quality of life, especially among those with younger age, lower monthly income, high disease activity, and types of psoriasis other than vulgaris.


Introduction
Psoriasis is a chronic, inflammatory condition that primarily affects the skin, hair, and the joints and associated with a significant humanistic and economic consequences (1,2) . It occurs in about 1% to 3% worldwide, (3) with higher prevalence in western countries. (4) The precise cause of psoriasis stills unclears (5) . Psoriasis is closely related to genetics, but environmental exposure plays an essential role in the disease development. (4) Obesity is another risk factor for psoriasis (6) . Many medicinal and chemical products, have been found to be related to the triggering and/or exacerbation of psoriasis including beta-adrenergic receptor blockers and tetracycline (7,8) .
Psoriasis is stimulated by the abnormal epidermal proliferation, leading to scaly erythematous plaques. (9) The pathophysiology of psoriasis includes an interplay between elements of the immune response, inflammatory components and an abnormal proliferation and differentiations of the keratinocytes, (10) results in scaly erythematous plaques. (9) Psoriasis has many different clinical presentations. The classic one is of red plaques and silver scale, (11) associated symptoms of itch, burning and soreness. (12) Psoriasis is classified as mild, moderate, or severe, relying on the percentage of the affected body surface area (BSA) and the Psoriasis Area and Severity Index (PASI). (13) The aims of treating psoriasis are to get an initial and fast control for disease symptoms, decrease the percentage of involved BSA, decrease plaque lesions, minimize adverse drug events, produce and maintain long-term remission, and improve the patient's quality of life (QOL). (11) Selection of treatment in patients with psoriasis depends on disease severity, (14) the presence of comorbid conditions, such as psoriatic arthritis, and treatment history. (15) Topical treatments are generally used as first-line therapy for most types of psoriasis (16) and include tar preparations, corticosteroids, calcipotriene, adarotene and anthralin. (11) Moderateto-severe psoriasis is usually treated by using systemic therapies. Methotrexate and biologics are the most-used systemic treatments for psoriasis. (17) Biologics are often the next step in the treatment when conventional systemic therapies fail or are contraindicated. (17) Biologics are very effective potent immunomodulatory drugs. (18) They are generally considered safe drugs but may be associated with rare serious adverse reactions such as malignancy and reactivation of tuberculosis. (19) The World Health Organization defined QOL as "the individuals 'perceptions of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns." (20) The QOL's value is important for knowing what is significant to the individuals' QOL since the principal goal for non-curative disease is to improve QOL. (21) Psoriasis can have a significant impact on patients' QOL and work productivity, depending on disease severity. (22) Symptoms of psoriasis are not limited to physical impact, they can also have strong psychosocial effects, (23) resulting in impaired emotional state, daily activity, and body image. (24) Accordingly, the aim of the current study was to evaluate QOL in a sample of Iraqi psoriatic patients and to determine possible association between QOL and some patient's related factors.

Patients
The current study was a cross-sectional study that involved 300 already diagnosed psoriasis patients (mean age was 35

The questionnaires
The QOL was assessed by using the Arabic version of Dermatology Life Quality Index (DLQI). The DLQI is a validated, dermatology-specific QOL instrument that was developed in the early 1990s , (25,26) and has been used in several trials for psoriasis, (25) The DLQI questionnaire consists of 10 questions, subdivided into 6 domains related to various aspects of a person's QOL: symptoms and feelings (questions one and two), daily activities (questions three and four), leisure (questions five and six), work/school (question seven), personal relationships (questions eight and nine), and treatment (question ten). Higher scores indicate greater deterioration of the patient's QOL and vice versa. (27) Total DLQI score between 0 and 1 indicates no effect on patient's QOL, 2-5 small effect, 6-10 moderate effect, 11-20 very large effect, and 21-30 indicates extremely large effect on patients' QOL. (14) Administration of the questionnaires When the patients arrived to the Center of Dermatology and Venereology for checkup and to receive their medications, they were interviewed by the researcher and asked if they are willing to participate in the current study, if they agreed, then a clarification of the questionnaire was given and each patient allowed to fill the research questionnaire which takes about 5-10 minutes to be filled completely.

Statistical analysis
The analyses were done by using the Statistical Package for the Social Science (SPSS, version 22, IBM, New York, USA). Descriptive statistics (means, standards deviations, frequencies and percentages) of the participants and disease were calculated. Multiple linear regression was used to measure the association between total DLQI score and multiple independent variables (sociodemographic and disease characteristics).

Results
Sociodemographic features of patients are represented in the Table 1. The most common type of psoriasis was vulgaris (77.7%) which followed by erythrodermic and psoriatic arthritis types (6.3%) (Figure 1).  Table 2).  Figure 2).  The total scores with their sub-scores of patient's DLQI are shown in Table 4. Since the average of total DLQI scores was more than 10 (11.2±5.49), that indicates that the patient's QOL is being seriously impacted by their skin disease. Multiple linear regression analyses were used to measure the association between different sociodemographic and disease characteristics (independent variables) and total DLQI score (dependent variables) of the participants. Age, monthly income and vulgaris type of psoriasis have significant negative association with total DLQI score. While PASI has significant positive association with the total DLQI score ( Table 6). Table 6. Association of total DLQI score with socio-demographic and disease characteristics variables of the participants BSA=Body surface area; PASI (Psoriasis Area Surface Index). *Significant association (P-value < 0.05). Gender (0=female vs 1 =male). NS=nonsignificant (P-value > 0.05). We excluded some highly non-significant variables (P-value > 0.6) (without mentioning ß) in some regression analyses to fit the model better. Types of psoriasis is binary variable = (0= non-vulgaris / 1= vulgaris).

Discussion
Psoriasis is a serious dermatological disease extending beyond the physical symptoms experienced by the patient, and seriously affecting the way in which the patient sees him /herself and the way he/she is seen by others. (28) In general, the commonly used measures of psoriasis activity are PASI and BSA. (29) The most widely used QOL questionnaire is the DLQI which is short and easy to use. (30) In the current study, more than one-half (53.7%) of the patients had a DLQI score of more than 10, which is more than that reported by a study done by Azura Mohd. et. al, where about 33.1% of patients had a DLQI score greater than 10, (4) which indicates a more deterioration in QOL for patients involved in the current study. The mean of total DLQI score is (11.29± 5.45) which is higher than that reported by Cacilda S. et. al, where the mean of DLQI score was (6.5 ± 6.9). (31) The largest impact was found in symptoms and feelings domain (mean score = 1.66±0.75). Similar findings were illustrated by Cacilda S. et. al, and Nilce´ia Lopes. et. al, where the greatest effect was noted for symptoms and feelings domain, asserting that emotion play an essential role in the QOL of patients with psoriasis, because the skin is largely responsible for an patient's appearance. (1,31) This mean that psoriasis has been associated with painful feelings of social anxiety and stigmatization, and fear of rejection. (32) The lowest impact was noted in personal relationships (score = 0.51± 0.65) which may be related to the fact that psoriasis is not contagious, so that the patient's family and partner can help patients and encourage them to face the disease and come with them to doctor and take medication. In contrast to the result of the current study, a study done in Brazil by Nilce´ia Lopes. et. al., showed that the lowest impact was in work and school. (1) In addition, the majority of the studied patients did not feel embarrassed during sexual activities regardless of the disease severity which is similar to the result reported by Amany Youssef. et. al. (28) This may be due that most husbands (wives) understand the non-infectious nature of the disease and encourage their husbands(wives) to cure and recover. However; contrary to current results, Głowacka et. al., illustrated that psoriasis limit patients' sexual life because of their embarrassment (28) . Studying the association between total DLQI score with various socio-demographic and disease characteristics variables of the participants revealed a significant negative association between age and total DLQI score ( Table 6). Similar finding had been reported from a study done in Korea by Sang Woong Youn. et. al. (29) This may be explained by that younger patients pay more attention to their shape than elderly patients, so the disease effect on their QOL is greater. However; results of study done  (28) Additionally, it was noted that patients with higher income was significantly associated with lower total DLQI score which mean better QOL (Table 6). Patients with higher monthly income can buy expensive medications which may be unavailable at public hospitals all the time and this might be reflected positively on their QOL. The results of this study showed a direct association between PASI and total DLQI score (Table 6), which is similar to the study done in Korea by Sang Woong Youn. et. al., where a greater impairment in QOL showed in patients with more severe psoriasis. (29) The predominant psoriasis type was plaque psoriasis (77.7%), which is consistent to the other studies done by Liliana G. et. al., (32) and Azura Mohd. et. al. (4) , where the plaque psoriasis was the most common type of psoriasis. Vulgaris type of psoriasis has negative association with total score of DLQI, this means that vulgaris type has lower negative effect on QOL. This may be explained by the natural course of each type. For example, erythrodermic psoriasis is characterized by abrupt development of erythematous, inflammatory skin plaques with edema (33) . Also the pustular type is a potentially lifethreatening variant of psoriasis characterized by a sudden and widespread development of superficial pustules that lead to bad appearance and cause anxiety and restlessness. (34)(35)(36) . In addition, psoriatic arthritis can cause irreversible damage to joints and supporting tissue. (37) which might be reflected negatively on quality of life of patients.

Conclusions
In conclusion, results of the current study document that psoriasis can exerts a significant, negative impact on patients' QOL, especially among those with younger age, lower monthly income, high disease activity, and types of psoriasis other than vulgaris. Accordingly, routine assessment is recommended for patients with psoriasis to detect and monitor the impact of the disease and treatment on patients' QOL with subsequent development of care plan to improve it especially in severely affected patients.

Limitations of the study
The first limitation was incorporating psoriatic patients from only one center in Baghdad city, so the data does not fully represent all Iraqi patients. In addition, the cross-sectional nature of the study makes it impossible to confirm causal conclusions.