**Clinical and Epidemiological Factors Predicting the Severity of Psoriasis**

Anca Chiriac, Cristian Podoleanu and Doina Azoicai

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.68728

#### **Abstract**

**Introduction:** Psoriasis, a systemic disease with a chronic course, is associated with a high degree of comorbidities and decreased quality of life.

**Aims:** The aims of the study were to analyze epidemiological data of a large cohort of patients diagnosed with psoriasis over 8 years and to assess factors related to psoriasis severity and impact on quality of life.

**Research methods:** A transversal study was performed on 1236 persons diagnosed with psoriasis in an OutPatient Dermatology Center between January 1, 2004 and December 31, 2011.

Clinical examination was done and medical records were complied including: type of psoriasis, number of body locations at the onset and at the moment of examination, severity index, family history of psoriasis, comorbidities, past and current treatments, demographic characteristics, residence, level of education, working status and income, smoking, and alcohol intake. Linear regression was used for multivariable analysis.

**Key results of the chapter:** Comorbidities were present in 36.1% of patients with mild form of psoriasis, 44.05% with moderate forms, and in 19.64% of severe psoriasis.

Onset and clinical examination age, education level, residence, job, gender, and smoking were significant factors associated with severity of psoriasis.

**Keywords:** psoriasis, epidemiological data, comorbidities, risk factors, severity index

© 2017 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

## **1. Introduction**

One of the most common T-cell-mediated diseases, psoriasis, is widely spread, potentially affecting 125 million people, or nearly 3% of the world's population [1–3]. Reports show that psoriasis affects as much as 2% of the UK population [4]. A significant number of UK psoriatic patients have a Dermatology Life Quality Index (DLQI) of >10, indicating that the disease strongly affects their lives [4]. Social factors such as stigmatization, psychological factors such as depression, and physical factors such as pruritus, pain, and other comorbidities have a great impact on the patient's life [5, 6].

Psoriasis involves high costs in the health-care system, represented by diagnosis, psychological counseling, investigations, treatments, and further research, which cannot be entirely quantified. A systematic review including 22 studies, published in *JAMA Dermatology 2015*, takes a comprehensive look at the cost of psoriasis in the USA by analyzing the expenses reported between 2008 and 2013, associated with the disease. In 2013, the US cost of psoriasis was estimated around \$112 billion. Researchers have described four categories of expenses associated with psoriasis. Direct costs represented by doctor's appointments, investigations, and therapies, have the highest expenses, estimated to be \$8000 annually per person. The cost of dealing with comorbidities such as heart disease and depression, extends the costs with almost \$5000 per person annually. Indirect costs are considered absences from work or lost productivity on the job, caused by psoriasis, and estimated to be upwards of \$4000 annually per person. The decreased quality of life with reduced selfconfidence and substantial stigmatization cannot be quantified or calculated in terms of cost—impalpable costs. US psoriatic patients would pay a lifetime cost of \$11,498 for treatment, relief of physical symptoms, emotional health, and reintegration into society. The direct psoriasis costs ranged from \$51.7 to \$63.2 billion, the indirect costs ranged from \$23.9 to \$35.4 billion, and medical comorbidities were estimated to be \$36.4 billion in 2013 [7]. On the strength of such high costs and the burden of seeking the right therapy, it is of great importance to assess psoriatic patients with comorbidities associated with severe disease and decreased quality of life.

Recent studies show that psoriatic patients have relatively higher risks of heart disease, stroke, hypertension, and diabetes. Furthermore, due to social isolation, patients are more prone to develop depression and anxiety compared to the general population [4–6, 8]. A national study in Taiwan performed on 51,800 patients diagnosed with psoriasis revealed a high prevalence ratio (relative risk (RR); [95% confidence interval (CI)]) for rheumatoid arthritis (3.02; [2.68, 3.41]), alopecia areata (4.71; [2.98, 7.45]), vitiligo (5.94; [3.79, 9.31]), pemphigus (41.81; [12.41, 140.90]), pemphigoid (14.75; [5.00, 43.50]), heart disease (1.32; [1.26, 1.37]), hypertension (1.51; [1.47, 1.56]), hyperglyceridemia (1.61; [1.54, 1.68]), diabetes (1.64; [1.58, 1.70]), hepatitis B viral infection (1.73; [1.47, 2.04]), hepatitis C viral infection (2.02; [1.67, 2.44]), systemic lupus erythematosus (6.16; [4.70, 8.09]), sleep disorder (3.89; [2.26, 6.71]), asthma (1.29; [1.18, 1.40]), allergic rhinitis (1.25; [1.18, 1.33]), chronic airways obstruction (1.47; [1.34, 1.61]), lip, oral cavity, and pharynx cancer (1.49; [1.22, 1.80]), digestive organs and peritoneum cancer (1.57; [1.41, 1.74]), and depression (1.50; [1.39, 1.61]) [8].

Psoriasis, a systemic disease with a chronic course, is associated with a high degree of comorbidities and decreased quality of life.

Psoriasis can vary tremendously in its severity. A number of studies investigated the factors that affect severity [9, 10]. They reported significant associations between psoriasis severity and comorbid diseases [10], male gender, younger age [11, 12], localization of the lesions [13], the presence of family history of psoriasis [14], smoking, and alcohol consumption [15]. The factors that affect severity are still not well characterized.

## **2. An overview of the transversal study**

**1. Introduction**

124 An Interdisciplinary Approach to Psoriasis

great impact on the patient's life [5, 6].

disease and decreased quality of life.

(1.50; [1.39, 1.61]) [8].

One of the most common T-cell-mediated diseases, psoriasis, is widely spread, potentially affecting 125 million people, or nearly 3% of the world's population [1–3]. Reports show that psoriasis affects as much as 2% of the UK population [4]. A significant number of UK psoriatic patients have a Dermatology Life Quality Index (DLQI) of >10, indicating that the disease strongly affects their lives [4]. Social factors such as stigmatization, psychological factors such as depression, and physical factors such as pruritus, pain, and other comorbidities have a

Psoriasis involves high costs in the health-care system, represented by diagnosis, psychological counseling, investigations, treatments, and further research, which cannot be entirely quantified. A systematic review including 22 studies, published in *JAMA Dermatology 2015*, takes a comprehensive look at the cost of psoriasis in the USA by analyzing the expenses reported between 2008 and 2013, associated with the disease. In 2013, the US cost of psoriasis was estimated around \$112 billion. Researchers have described four categories of expenses associated with psoriasis. Direct costs represented by doctor's appointments, investigations, and therapies, have the highest expenses, estimated to be \$8000 annually per person. The cost of dealing with comorbidities such as heart disease and depression, extends the costs with almost \$5000 per person annually. Indirect costs are considered absences from work or lost productivity on the job, caused by psoriasis, and estimated to be upwards of \$4000 annually per person. The decreased quality of life with reduced selfconfidence and substantial stigmatization cannot be quantified or calculated in terms of cost—impalpable costs. US psoriatic patients would pay a lifetime cost of \$11,498 for treatment, relief of physical symptoms, emotional health, and reintegration into society. The direct psoriasis costs ranged from \$51.7 to \$63.2 billion, the indirect costs ranged from \$23.9 to \$35.4 billion, and medical comorbidities were estimated to be \$36.4 billion in 2013 [7]. On the strength of such high costs and the burden of seeking the right therapy, it is of great importance to assess psoriatic patients with comorbidities associated with severe

Recent studies show that psoriatic patients have relatively higher risks of heart disease, stroke, hypertension, and diabetes. Furthermore, due to social isolation, patients are more prone to develop depression and anxiety compared to the general population [4–6, 8]. A national study in Taiwan performed on 51,800 patients diagnosed with psoriasis revealed a high prevalence ratio (relative risk (RR); [95% confidence interval (CI)]) for rheumatoid arthritis (3.02; [2.68, 3.41]), alopecia areata (4.71; [2.98, 7.45]), vitiligo (5.94; [3.79, 9.31]), pemphigus (41.81; [12.41, 140.90]), pemphigoid (14.75; [5.00, 43.50]), heart disease (1.32; [1.26, 1.37]), hypertension (1.51; [1.47, 1.56]), hyperglyceridemia (1.61; [1.54, 1.68]), diabetes (1.64; [1.58, 1.70]), hepatitis B viral infection (1.73; [1.47, 2.04]), hepatitis C viral infection (2.02; [1.67, 2.44]), systemic lupus erythematosus (6.16; [4.70, 8.09]), sleep disorder (3.89; [2.26, 6.71]), asthma (1.29; [1.18, 1.40]), allergic rhinitis (1.25; [1.18, 1.33]), chronic airways obstruction (1.47; [1.34, 1.61]), lip, oral cavity, and pharynx cancer (1.49; [1.22, 1.80]), digestive organs and peritoneum cancer (1.57; [1.41, 1.74]), and depression

## **2.1. Aims and objectives of the study: methods and materials**

**The aim of this study** was to evaluate clinical and epidemiological characteristics of the psoriatic population for establishing prevention strategies and optimal clinical management.

**The objectives of this transversal study** were to analyze epidemiological data of a large cohort of patients diagnosed with psoriasis over a period of 8 years and to assess factors related to psoriasis severity and impact on their quality of life (validated by Psoriasis Area and Severity Index (PASI) index and DLQI).

All the investigations were conducted in an outpatient clinic specialized for psoriasis and investigative dermatology, in the north-eastern region of Romania, over a period of 8 years. **Study** was performed on **1236 persons** diagnosed with psoriasis **between January 1, 2004 and December 31, 2011**.

Participants were examined for psoriasis by the same two dermatologists, under similar conditions. All patients had a complete physical examination and their medical history was recorded.

Psoriasis was diagnosed by dermatological examination and was confirmed by punch skin biopsy, when needed. Skin biopsies were performed at a representative psoriatic plaque of each patient.

In other articles [16, 17], psoriasis is classified as mild, moderate, and severe, based on clinical evaluation tools such as the extent of the affected skin surface. In this study, in order to quantify the severity of the disease, PASI was used; patients were categorized into mild (PASI: 0.0–4.0), moderate (4.1–9.9), and severe (10 or higher) psoriasis.

Patient data and medical history were collected from the Specialized Psoriasis Clinic, over a period of 8 years. Written informed consent was obtained from all patients.

The data collected by our dermatologists included the following:

**1. demographic characteristics**: gender, date of birth, age of the patients at the moment of examination, level of education, occupation (jobs distribution, respectively, socioeconomic status), residence;


## *2.1.1. Statistical analysis*

All statistical analyses were conducted using Statistical Analysis System software.

Patient data were presented as proportions, standard deviations, means, and ranges. Linear regression was used for multivariable analysis of factors affecting psoriasis severity. Specified variables were included in the analysis of index severity. Spearman's rank coefficient of correlation was used as a nonparametric measure of dependence. Pearson's chi-squared test to quantify differences was used. All statistical tests had a confidence interval of 95% and the significance level was set at *p <* 0.05.

## **2.2. Results and discussion**

#### *2.2.1. Demographic data*

## *2.2.1.1. Gender distribution*

Out of the 1236 patients diagnosed with psoriasis, 669 were men (54.13%) and 567 (45.87%) were women, showing a *predominance of male over female gender* **(1.18/1)**.

#### *2.2.1.2. Age distribution at the moment of examination*

**The highest incidence** of the disease was noticed for the *age group 30–50 years old* (43.12%); **the minimal incidence** was *over 70 years* (5.83%) and *under 20 years* (5.5%). Statistically 50% of cases were over 40 years and 25% under 33 years.

The median value for age was 44.94 ± 15.84 standard deviation (SD), with a great variability from 6 to 91 years old. Psoriasis can occur at any age; patients should seek medical advice regardless of age.

#### *2.2.1.3. Distribution of cases reported to residence*

As shown in **Table 1**, urban patients prevail. People living in villages have low incidence of psoriasis, reflecting a real reduced number of cases or a smaller addressability to medical care (**Figure 1**).


**Table 1.** Results of the study: number of patients reported to residence.

#### *2.2.1.4. Level of education*

**2. psoriasis—clinical-related data:** family history of psoriasis, age distribution at the onset of psoriasis, distribution of psoriatic lesions at the moment of diagnosis and at the moment of

**3. comorbidities** such as thyroid abnormalities, cardiovascular disease (CVD), hypertension,

**4. severity of lesions in relation to evolution characteristics:** smoking history, alcohol con-

Patient data were presented as proportions, standard deviations, means, and ranges. Linear regression was used for multivariable analysis of factors affecting psoriasis severity. Specified variables were included in the analysis of index severity. Spearman's rank coefficient of correlation was used as a nonparametric measure of dependence. Pearson's chi-squared test to quantify differences was used. All statistical tests had a confidence interval of 95% and the

Out of the 1236 patients diagnosed with psoriasis, 669 were men (54.13%) and 567 (45.87%)

**The highest incidence** of the disease was noticed for the *age group 30–50 years old* (43.12%); **the minimal incidence** was *over 70 years* (5.83%) and *under 20 years* (5.5%). Statistically 50% of

The median value for age was 44.94 ± 15.84 standard deviation (SD), with a great variability from 6 to 91 years old. Psoriasis can occur at any age; patients should seek medical advice

As shown in **Table 1**, urban patients prevail. People living in villages have low incidence of psoriasis, reflecting a real reduced number of cases or a smaller addressability to medical care

were women, showing a *predominance of male over female gender* **(1.18/1)**.

*2.2.1.2. Age distribution at the moment of examination*

cases were over 40 years and 25% under 33 years.

*2.2.1.3. Distribution of cases reported to residence*

clinical inspection, number of areas involved, symptoms such as pruritus;

All statistical analyses were conducted using Statistical Analysis System software.

other concomitant skin disorders, and others;

*2.1.1. Statistical analysis*

126 An Interdisciplinary Approach to Psoriasis

significance level was set at *p <* 0.05.

**2.2. Results and discussion**

*2.2.1. Demographic data*

regardless of age.

(**Figure 1**).

*2.2.1.1. Gender distribution*

sumption, past and current therapies with topical steroids.

The level of education correlates with the prevalence of psoriasis (**Table 2**). This can be explained by stress, underlying the western modern lifestyle.

## *2.2.1.5. Occupational characteristics at the moment of medical examination: jobs distribution, respectively, socioeconomic status*

Present data confirm the high prevalence of psoriasis in working people, especially in stressful activities: engineers, students, professors, managers, drivers, salesmen, and medical staff. Physical activity, alcohol consumption, smoking, pollution from the working place, repeated trauma, and irritants are linked to psoriasis on workers.

**Figure 1.** Results of the study: distribution of cases reported to residence.

Retired persons encounter a frequent diagnosis of psoriasis after a long evolution of the disease (psoriasis march), even though they allocate time and money in search of medical help. This can be explained by the fact that chronic infections, comorbidities, and drug administration could be a potential trigger for psoriasis flares.

#### *2.2.2. Diagnosis of psoriasis and clinical data*

## *2.2.2.1. Family history of psoriasis*

*Out of the 1236 patients, a positive family history of psoriasis was found in 380 patients (59.37%);* of these, 174 (27.18%) had at least one parent with psoriasis, with a λR of 13.59, while 106 patients (16.56%) had at least one second-degree relative with psoriasis, and 34 patients (5.31%) had one-third-degree relative with psoriasis (**Figure 2**). No parent-of-origin effect in transmission of psoriasis from affected parent to offspring was observed, and there were no significant differences in the clinical profiles of the disease between patients grouped by transmission pattern of psoriasis.

## *2.2.2.2. Age of the patients at the onset of psoriasis*

Results of the study showed the following: 7.77% of patients did not recall the age at which the first lesions appeared, 46.04% had the first diagnosis of psoriasis somewhere between 10 and 30 years old, and the fewest cases were detected over the age of 50 (11.17%).

The median age at the diagnosis is 29.34 ± 15.24 SD, with the youngest patient being 6 months (neonatal psoriasis) and oldest 76 years.

Statistically 50% of cases were less than 27 years old at the moment of first medical seek and 25% over 39 years old when they accepted psoriasis as a diagnosis (**Table 3**). Within this group, there were 104 cases (8.41%) with the onset of psoriasis under the age of 10 and 263 (21.28%) of cases had the first certified diagnosis of psoriasis before 19 years old. The majority of cases were adult psoriasis 869 (70.31%).


**Table 2.** Results of the study: level of education among patients diagnosed with psoriasis.

**Figure 2.** Results of the study: family history reported.

Retired persons encounter a frequent diagnosis of psoriasis after a long evolution of the disease (psoriasis march), even though they allocate time and money in search of medical help. This can be explained by the fact that chronic infections, comorbidities, and drug administra-

*Out of the 1236 patients, a positive family history of psoriasis was found in 380 patients (59.37%);* of these, 174 (27.18%) had at least one parent with psoriasis, with a λR of 13.59, while 106 patients (16.56%) had at least one second-degree relative with psoriasis, and 34 patients (5.31%) had one-third-degree relative with psoriasis (**Figure 2**). No parent-of-origin effect in transmission of psoriasis from affected parent to offspring was observed, and there were no significant differences in the clinical profiles of the disease between patients grouped by transmission

Results of the study showed the following: 7.77% of patients did not recall the age at which the first lesions appeared, 46.04% had the first diagnosis of psoriasis somewhere between 10

The median age at the diagnosis is 29.34 ± 15.24 SD, with the youngest patient being 6 months

Statistically 50% of cases were less than 27 years old at the moment of first medical seek and 25% over 39 years old when they accepted psoriasis as a diagnosis (**Table 3**). Within this group, there were 104 cases (8.41%) with the onset of psoriasis under the age of 10 and 263 (21.28%) of cases had the first certified diagnosis of psoriasis before 19 years old. The majority

and 30 years old, and the fewest cases were detected over the age of 50 (11.17%).

**Level of education Nr. cases %** Middle school 54 4.37 College 148 11.97 Vocational school 48 3.88 High school 345 27.91 Postsecondary school 47 3.80 Students 182 14.72 University graduates 412 33.33

**Table 2.** Results of the study: level of education among patients diagnosed with psoriasis.

tion could be a potential trigger for psoriasis flares.

*2.2.2. Diagnosis of psoriasis and clinical data*

*2.2.2.2. Age of the patients at the onset of psoriasis*

(neonatal psoriasis) and oldest 76 years.

of cases were adult psoriasis 869 (70.31%).

Total 1236

*2.2.2.1. Family history of psoriasis*

128 An Interdisciplinary Approach to Psoriasis

pattern of psoriasis.


**Table 3.** Results of the study: age of the patients at the onset of psoriasis.

Psoriasis has been reported as a chronic disease that begins in one-third of the patients during the first two decades of life [18]. Several prevalence studies have published their results showing that one-third of psoriatic patients develop the disease during childhood [19]. A fast increase in the incidence rate of psoriasis until the age of 30–35 years was recently reported [20].

Childhood onset of psoriasis was not proven to be a risk factor for higher frequencies of cardiovascular and metabolic comorbidities during adulthood in a recent French study [21]. Moreover, the age of onset of psoriasis had no impact on the severity of the disease in another retrospective study conducted in Greece [22]. No evidence was found that under 18 years may influence the disease severity in later life [23].

Similar data have been obtained by present analysis: 70.31% of patients enrolled in the study were diagnosed after the age of 20, only 104 cases (8.41%) had the onset before the age of 10; 263 (21.28%) of cases were diagnosed between 10 and 19 years old.

Psoriasis in children should not be considered as underreported because parents seek for medical care for their children at the first signs of skin injury. Children with psoriatic arthritis (PsA) were not included in the study.

## *2.2.2.3. The distribution of psoriatic lesions at the moment of diagnosis (Single lesion or multiple distributions of cutaneous manifestations declared by patients)*

The majority of cases **(91.18%)** had *a unique lesion* of psoriasis *when they were first diagnosed*, multiple locations being much rarer (8.82%). Among the unique first clinical signs, most of the patients (28.07%) reported **scalp** being involved, followed by **elbows** (11.89%), **palms** (7.93%), **feet** (7.12%), and **trunk** (5.18%). A significant number of persons involved in the study were not able to remember the first location of psoriasis (10.36%).

*2.2.2.4. The distribution of psoriatic lesions at the moment of clinical inspection (Single lesion or multiple distributions of cutaneous manifestations)*

*The majority of patients* **(82.85%)** *had* **multiple skin lesions** *at the moment of clinical inspection* (**Table 4**).

The distribution of psoriasis was recorded. Active lesions were noted on the scalp, face, trunk, anogenital area, arms, legs, hands, feet, or nails, that is, in 10 different locations (**Figure 3**):


**Table 4.** Results of the study: distribution of multiple skin lesions at the moment of clinical inspection.

Similar data have been obtained by present analysis: 70.31% of patients enrolled in the study were diagnosed after the age of 20, only 104 cases (8.41%) had the onset before the age of 10;

Psoriasis in children should not be considered as underreported because parents seek for medical care for their children at the first signs of skin injury. Children with psoriatic arthritis

*2.2.2.3. The distribution of psoriatic lesions at the moment of diagnosis (Single lesion or multiple* 

*2.2.2.4. The distribution of psoriatic lesions at the moment of clinical inspection (Single lesion or* 

*The majority of patients* **(82.85%)** *had* **multiple skin lesions** *at the moment of clinical inspection*

The distribution of psoriasis was recorded. Active lesions were noted on the scalp, face, trunk, anogenital area, arms, legs, hands, feet, or nails, that is, in 10 different locations (**Figure 3**):

**Nr. cases %**

The majority of cases **(91.18%)** had *a unique lesion* of psoriasis *when they were first diagnosed*, multiple locations being much rarer (8.82%). Among the unique first clinical signs, most of the patients (28.07%) reported **scalp** being involved, followed by **elbows** (11.89%), **palms** (7.93%), **feet** (7.12%), and **trunk** (5.18%). A significant number of persons involved in the study were

263 (21.28%) of cases were diagnosed between 10 and 19 years old.

*distributions of cutaneous manifestations declared by patients)*

not able to remember the first location of psoriasis (10.36%).

Nail psoriasis 165 13.35 **Psoriatic arthritis** 309 25.00 Koebner phenomena 173 14.00 **Scalp psoriasis** 681 55.10 Gutate psoriasis 146 11.81 **Superior limbs** 788 63.75 **Inferior limbs** 736 59.55 **Trunk** 462 37.38 Face 55 4.45 Palmo-plantar 205 16.59 Others 265 21.44

**Table 4.** Results of the study: distribution of multiple skin lesions at the moment of clinical inspection.

*multiple distributions of cutaneous manifestations)*

**Total** 1236

(**Table 4**).

(PsA) were not included in the study.

130 An Interdisciplinary Approach to Psoriasis

## *2.2.2.5. Number of areas involved at the moment of clinical inspection (By single or multiple cutaneous lesions)*

Out of the 1236 patients enrolled in the study, an *approximately equal distribution* was observed among patients with **solitary lesion or two, three, or four body areas involved** (**Table 5**). More generalized forms were very rare (**Figure 4**).

#### *2.2.2.6. Evolution of psoriatic lesions from diagnosis to present clinical inspection*

Few patients (1.21%) with *multiple onset lesions* later **turned to have** *unique lesions*, while 7.61% of them **preserved** the initial multiple lesions; 15.94% of patients with *onset single lesions* remained with a unique cutaneous psoriasis stigma (the same of different location) (**Table 6**).

The vast majority of cases (75.24%) with declared unique psoriatic lesion at the onset of the disease **developed** *multiple skin manifestations* over short or long periods of time.

The statistical report shows **no marked relationship** between the lesions location at the time of the first diagnosis of psoriasis and at the moment of onset evaluation (*r* = 0.1406, *χ*<sup>2</sup> = 1.018, *p* = 0.312, 95% CI).

The comparison between unique onset lesion and multiple lesions at the moment of clinical examination is presented in (**Table 7**).

#### *2.2.2.7. Symptoms: pruritus and psoriasis*

Previous dermatology dogma suggested that atopic dermatitis is itchy and psoriasis is not!


**Table 5.** Number of areas involved.

**Figure 4.** Body areas frequently involved.

The aim of the present study was to assess the incidence of pruritus in patients diagnosed with psoriasis (**Figure 5**); data were collected based on patients' responses and pruritus was certified by declaration.


The aim of the present study was to assess the incidence of pruritus in patients diagnosed with psoriasis (**Figure 5**); data were collected based on patients' responses and pruritus was

**Location Nr. cases %** Unique lesion 212 17.15 Multiple lesions 1024 82.85 Two body areas 266 21.55 Three body areas 244 19.74 Four body areas 240 19.41 Five body areas 155 12.54 Six body areas 76 6.15 Seven body areas 30 2.43 Eight body areas 12 0.97 10 body areas 1 0.08

Total 1236

**Table 5.** Number of areas involved.

132 An Interdisciplinary Approach to Psoriasis

certified by declaration.

**Figure 4.** Body areas frequently involved.

Dorsal aspects of the hands, feet 4 0.32


#### **Table 6.** Number of areas involved.


**Table 7.** The number of psoriatic lesions found in time of diagnosis as compared with the number found at clinical inspection.

*Pruritus was admitted* by 293 persons **(23.7%)** and *denied* by 943 **(76.3%)**. The presence and intensity of pruritus were independent of age, gender, marital status, family history of psoriasis, job, level of education, type of psoriasis, alcohol, smoking, duration of the disease, number of lesions, and severity index.

Pruritus may be unrecognized and underestimated by the patients and/or medical staff.

#### *2.2.3. Comorbidities*

#### *2.2.3.1. Comorbidities: overview*

Comorbidities present at the moment of diagnosis and/or in the medical history of patients (**Figure 6**, **Table 8**).

Out of the 1236 patients enrolled in the study, 59.22% (732 psoriatic patients) had no comorbidities at the moment of diagnosis or in their medical history (**Table 8**).

#### *2.2.3.2. Comorbidities: psoriasis and psoriatic arthritis*

Psoriatic arthritis is a chronic, inflammatory, seronegative form of arthritis occurring in subjects with psoriasis. PsA usually occurs over the age of 40 and it affects both sexes equally [24, 25].

**Figure 5.** Results of the study: pruritus and psoriasis.

*Pruritus was admitted* by 293 persons **(23.7%)** and *denied* by 943 **(76.3%)**. The presence and intensity of pruritus were independent of age, gender, marital status, family history of psoriasis, job, level of education, type of psoriasis, alcohol, smoking, duration of the disease, number

**Table 7.** The number of psoriatic lesions found in time of diagnosis as compared with the number found at clinical

15.94% 75.24%

1.21% 7.61%

*multiple lesions* **at the onset of evaluation**

Dorsal aspects of the hands, face

Cervical, retroauricular

**Unique location Multiple locations**

**Nr. cases %**

1 0.08

1 0.08

Plantar, abdomen 1 0.08

Pruritus may be unrecognized and underestimated by the patients and/or medical staff.

Comorbidities present at the moment of diagnosis and/or in the medical history of patients

Out of the 1236 patients enrolled in the study, 59.22% (732 psoriatic patients) had no comor-

Psoriatic arthritis is a chronic, inflammatory, seronegative form of arthritis occurring in subjects with psoriasis. PsA usually occurs over the age of 40 and it affects both sexes equally [24, 25].

bidities at the moment of diagnosis or in their medical history (**Table 8**).

**Onset** *unique lesion* **Nr. cases % Associations of** 

Total 1127 Total 109

**Onset location Location at the moment of examination Total**

ONSET: unique location 197 930 1127

ONSET: multiple location 15 94 109

Total 212 1024 1236

*2.2.3.2. Comorbidities: psoriasis and psoriatic arthritis*

of lesions, and severity index.

**Table 6.** Number of areas involved.

134 An Interdisciplinary Approach to Psoriasis

*2.2.3.1. Comorbidities: overview*

*2.2.3. Comorbidities*

inspection.

(**Figure 6**, **Table 8**).

**Figure 6.** The number of patients with present/absent comorbidities at the moment of diagnosis and/or in their medical history.

The incidence and prevalence of PsA among patients with psoriasis varies between different studies based on the variety of criteria and methods used to study PsA such as patient history, questionnaires, Moll and Wright or Caspar and Grappa classification criteria [26]. Prey et al. published a review where prevalence ranged from 2.04 to 26% and 5.94 to 25% when evaluating PsA using only rheumatologic diagnostic criteria [26].

Likewise, geographical variations in PsA were notified: Europe and North America present higher PsA prevalence ranging between 20.6 and 30% compared with Asia where PsA is significantly lower (8.7%) as seen in a large study of 1149 patients, in Argentina the prevalence rate was found to be 17%, whereas in Brazil 35% [27–31].



**Comorbidities**

Absent Arterial hypertension

Cardiac dysrhythmia

Ischemic heart disease

DZ II DZ insulin-dependent

Dysmetabolic syndrome

Morbid obesity

Chronic hepatitis B

Chronic hepatitis C

Toxic chronic hepatitis

Liver cirrhosis

Hepatic steatosis

Hepatitis B virus carrier

Hepatic cyst hydatid

Tuberculosis

Peptic ulcer

Gastritis Gastric hemorrhage

Disc herniation

Gout Rheumatoid arthritis

4

0.32

Cancer colorectal

1

0.08

Fibrocystic breast disease

 6

21

3

0.24

Breast cancer

1

0.08

Ovarian cysts

8

0.64

0.49

1.68

Hodgkin disease

1

0.08

Fibroma uterus

14

1.12

2

0.16

Cervical cancer

2

0.16

Endometriosis

1

0.08

12 36

8

0.64

Spastic tetraparesis

1

0.08

Phimosis

2.91

Parkinson disease

1

0.08

Azoospermia

0.96

Meningitis

1

0.08

Status epilepticus

1 1

0.08

Hydrocele

0.08

Testicular ectopia

1 5 1 2

0.16

0.08

0.40

0.08

 1

0.08

Infantile paralysis

1

0.08

3

0.24

Ischemic stroke

5

0.40

Chronic

glomerulonephritis

Chronic urinary tract

1

0.08

infection

2

0.16

Megacolon surgery

1

0.08

Enuresis

28

2.24

Inguinal hernia

5

0.40

7

0.56

Ovarectomy

10

0.08

Hysterectomy

1 6

0.49

Renal lithiasis

Chronic pyelonephritis

2 1 1

0.08

0.08

0.16

9

0.73

0.08

Biliary lithiasis

4

0.32

16

1.28

Splenectomy

1

0.08

18

1.44

Colecystectomy

16

1.28

Umbilical hernia

Chronic cholecystitis

8

0.65

2

0.16

3

0.24

Adenoidectomy

13

1.04

Hiatal hernia

1

0.08

20 47

3.79

Amygdalectomy

10

0.80

1.16

Acne

18

1.44

Quincke edema

1 1

0.08

Gilbert syndrome

Chronic pancreatitis

3

0.24

1

0.08

0.08

Hay fever

124

9.92

Lyell syndrome

1

0.08

Sinusitis

*N*

732

59.22

Chronic urticaria

2

0.16

Allergic rhinitis

1 2 1

0.08

136 An Interdisciplinary Approach to Psoriasis

0.16

0.08

**%**

**Comorbidities**

*N*

**%**

**Comorbidities**

*N*

**%**

**8.** General comorbidities among psoriatic patients involved in the study.

> **Table**

In our study, the estimated PsA prevalence based on rheumatologic evaluation (Moll and Wright criteria) was **0.16%** among 1236 patients with psoriasis (**Table 9**), **NOT** in accord with several European revisions.

An extensive study in Germany on 1511 patients revealed a total PsA prevalence of 20.5% [31]. In Greece, a retrospective analysis on 278 patients with psoriasis revealed that PsA prevalence was 30%. This subgroup of patients with PsA showed significantly higher rates of comorbidities including CVD, hypertension, diabetes mellitus type 2, and hypercholesterolemia compared to non-PsA patients [24]. Other studies show PsA prevalence ranging between 0.17 and 0.35% in the general Greek population [32, 33]. Other two publications report remarkably lower rates of PsA prevalence among patients with psoriasis, 7.23% in Croatia, respectively, 9.3% in Serbia [26].

## *2.2.3.3. Comorbidities: coexistence of psoriasis with other skin diseases at the moment of diagnosis*

Out of the 1236 patients enrolled in the study, only 26 psoriatic patients had other skin diseases at the moment of diagnosis (**Table 10**), including 10 with vitiligo, 3 with dermatomyositis, 3 with Rosacea, and 2 with Alopecia areata.

## *2.2.3.4. Comorbidities: coexistence of psoriasis with cardiovascular diseases at the moment of diagnosis*

Psoriasis has been associated with high cardiovascular morbidity and mortality. Recent studies suggest that psoriasis, particularly if severe, has a 58% increased risk of major adverse cardiovascular events such as arrhythmia, myocardial infarction, or stroke, and has a 57% increased risk of cardiovascular death, beyond the risk of death associated with traditional cardiovascular risk factors [34–36].

Of the 1236 patients enrolled in the study, 162 psoriatic patients had cardiovascular diseases at the moment of diagnosis (**Table 11**), great majority accusing arterial hypertension.


**Table 9.** Coexistence of psoriasis with other rheumatologic diseases.

#### *2.2.3.5. Comorbidities: prevalence of thyroid abnormalities among psoriatic patients*

Of the 1236 patients diagnosed with psoriasis, only 22 were spotted with thyroid abnormalities (**Table 12**).


**Table 10.** Coexistence of psoriasis with other skin diseases.

In our study, the estimated PsA prevalence based on rheumatologic evaluation (Moll and Wright criteria) was **0.16%** among 1236 patients with psoriasis (**Table 9**), **NOT** in accord with

An extensive study in Germany on 1511 patients revealed a total PsA prevalence of 20.5% [31]. In Greece, a retrospective analysis on 278 patients with psoriasis revealed that PsA prevalence was 30%. This subgroup of patients with PsA showed significantly higher rates of comorbidities including CVD, hypertension, diabetes mellitus type 2, and hypercholesterolemia compared to non-PsA patients [24]. Other studies show PsA prevalence ranging between 0.17 and 0.35% in the general Greek population [32, 33]. Other two publications report remarkably lower rates of PsA prevalence among patients with psoriasis, 7.23% in Croatia, respectively, 9.3% in Serbia [26].

*2.2.3.3. Comorbidities: coexistence of psoriasis with other skin diseases at the moment of diagnosis*

Out of the 1236 patients enrolled in the study, only 26 psoriatic patients had other skin diseases at the moment of diagnosis (**Table 10**), including 10 with vitiligo, 3 with dermatomyosi-

*2.2.3.4. Comorbidities: coexistence of psoriasis with cardiovascular diseases at the moment of diagnosis*

Psoriasis has been associated with high cardiovascular morbidity and mortality. Recent studies suggest that psoriasis, particularly if severe, has a 58% increased risk of major adverse cardiovascular events such as arrhythmia, myocardial infarction, or stroke, and has a 57% increased risk of cardiovascular death, beyond the risk of death associated with traditional

Of the 1236 patients enrolled in the study, 162 psoriatic patients had cardiovascular diseases

at the moment of diagnosis (**Table 11**), great majority accusing arterial hypertension.

**Coexistence of rheumatologic diseases Nr. cases %** Disc herniation 21 1.68 Gout 3 0.24 Rheumatoid arthritis 4 0.32 Ankylosing spondylitis 4 0.32 Rheumatic fever 1 0.08 Osteitis 1 0.08 Psoriatic arthritis 2 0.16 Knee meniscus graft 1 0.08 Osteomyelitis 2 0.16 Cervical spondylotic 2 0.16

several European revisions.

138 An Interdisciplinary Approach to Psoriasis

tis, 3 with Rosacea, and 2 with Alopecia areata.

Total 68/1236

**Table 9.** Coexistence of psoriasis with other rheumatologic diseases.

cardiovascular risk factors [34–36].


**Table 11.** Cardiovascular diseases among psoriatic patients involved in the study.


**Table 12.** Coexistence of thyroid abnormalities at patients diagnosed with psoriasis.

## *2.2.3.6. Comorbidities: psoriasis and tuberculosis*

In this transversal study, the incidence of tuberculosis was quantified from the medical history and at the moment of the clinical examination for patients diagnosed with psoriasis. Of the 1236 patients diagnosed with psoriasis, over a period of 8 years (2004–2011) comorbidities were present in **40.78%** of cases, and **12** of them **(0.97%)** had **a history of tuberculosis**: 5 were men (41.67%), 8 cases of pulmonary tuberculosis (66.67%), 2 pleural effusions (16.67%), 1 genital tuberculosis (8.34%), and 1 case of kerato-conjunctivitis (8.34%). Of the 12 patients with psoriasis and past tuberculosis, 1 had arterial hypertension and chronic nephritis, 1 obesity, 1 erythema nodosum, and 1 with gastric carcinoma (**Figure 7**).

Psoriasis could represent an independent risk factor for tuberculosis, because a high prevalence was reported in recent studies: 18.0%—Bordignon et al. [37]. In another study, latent tuberculosis infection was more reported in psoriasis (50%) than inflammatory bowel disease patients (24.2%), prior to the onset of any anti-tumor necrosis factor (TNF)-α treatment [38].

## *2.2.4. Evolution characteristics*

## *2.2.4.1. Severity of lesions in relation to risk factors*

The number of psoriatic lesions is in direct relation with the risk factors, including residence, gender, index severity, presence of comorbidities, alcohol intake, smoking, work status, and family history of psoriasis (**Table 13**).

## *2.2.4.2. Severity of lesions in relation to risk factors: smoking and psoriasis*

*Most of the patients* enrolled in the study were **nonsmokers**, *by declaration* (**Figure 8**) but **there is a significant correlation between the smoking and the severity of the disease** (*r* = 0.254, *χ*2 = 10.49, *p* = 0.00527, 95% CI).

**Figure 7.** Tuberculosis among psoriatic patients involved in the study.


*2.2.3.6. Comorbidities: psoriasis and tuberculosis*

140 An Interdisciplinary Approach to Psoriasis

*2.2.4. Evolution characteristics*

*χ*2

*2.2.4.1. Severity of lesions in relation to risk factors*

family history of psoriasis (**Table 13**).

= 10.49, *p* = 0.00527, 95% CI).

1 erythema nodosum, and 1 with gastric carcinoma (**Figure 7**).

*2.2.4.2. Severity of lesions in relation to risk factors: smoking and psoriasis*

**Figure 7.** Tuberculosis among psoriatic patients involved in the study.

In this transversal study, the incidence of tuberculosis was quantified from the medical history and at the moment of the clinical examination for patients diagnosed with psoriasis. Of the 1236 patients diagnosed with psoriasis, over a period of 8 years (2004–2011) comorbidities were present in **40.78%** of cases, and **12** of them **(0.97%)** had **a history of tuberculosis**: 5 were men (41.67%), 8 cases of pulmonary tuberculosis (66.67%), 2 pleural effusions (16.67%), 1 genital tuberculosis (8.34%), and 1 case of kerato-conjunctivitis (8.34%). Of the 12 patients with psoriasis and past tuberculosis, 1 had arterial hypertension and chronic nephritis, 1 obesity,

Psoriasis could represent an independent risk factor for tuberculosis, because a high prevalence was reported in recent studies: 18.0%—Bordignon et al. [37]. In another study, latent tuberculosis infection was more reported in psoriasis (50%) than inflammatory bowel disease patients

The number of psoriatic lesions is in direct relation with the risk factors, including residence, gender, index severity, presence of comorbidities, alcohol intake, smoking, work status, and

*Most of the patients* enrolled in the study were **nonsmokers**, *by declaration* (**Figure 8**) but **there is a significant correlation between the smoking and the severity of the disease** (*r* = 0.254,

(24.2%), prior to the onset of any anti-tumor necrosis factor (TNF)-α treatment [38].

**Table 13.** Number of lesions in relation to risk factors (residence, gender, index severity, presence of comorbidities, alcohol intake, smoking, work status, and family history of psoriasis).

*2.2.4.3. Severity of lesions in relation to risk factors: alcohol intake (by declaration) and psoriasis*

Of 1236 patients with psoriasis, alcohol consumption was declared by 410 persons, representing 33.17% of all (**Table 14**).

**Figure 8.** Results of the study: smokers and nonsmokers involved in the study.


**Table 14.** Results of the study: number of patients in relation with alcohol consumption.

#### *2.2.4.4. Severity of lesions in relation to PASI*

The number of psoriasis lesions correlates with (**Table 15**):


#### *2.2.4.5. Severity of lesions in relation with topical steroids*

**Topical steroids**: most of the patients were several years treated with steroids topically before presenting to the clinical appointment (**Table 16**).

## **2.3. Correlations with the severity of psoriasis (Risk factors)**

Severity index of the disease at the moment of clinical examination (**Table 17**) are as follows:

Within psoriasis patients, 43.37% were diagnosed with mild form of the disease, 40.45% with moderate, and only 16.18% with severe type.

#### *2.3.1. Correlations between demographic data and the severity index of psoriasis*

#### *2.3.1.1. Gender distribution versus severity index*

There is a strong correlation between gender and severity of the disease (*r* = 0.378, *p* = 0.00023, *χ*2 = 16.706, *p* = 0.00024, 95% CI) (**Table 18**). Among severe cases, 19.8% were men and only 11.82% women, in comparison with mild cases where 47.62% were women (**Figure 9**).


**Table 15.** Results of the study: severity of lesions in relation to PASI.

*2.2.4.4. Severity of lesions in relation to PASI*

Total 1236

142 An Interdisciplinary Approach to Psoriasis

• residence in rural area (*χ*<sup>2</sup>

• alcohol intake (*χ*<sup>2</sup>

• smoking (*χ*<sup>2</sup>

The number of psoriasis lesions correlates with (**Table 15**):

**Figure 8.** Results of the study: smokers and nonsmokers involved in the study.

**Alcohol consumption Nr. cases %** Positive 410 33.17 Negative 826 66.83

**Table 14.** Results of the study: number of patients in relation with alcohol consumption.

• occupation: workers/pupils/students (*χ*<sup>2</sup>

• age at the moment of clinical examination (*F* = 8.902, *p* = 0.0029);

= 16.47, *p* = 0.00005, 95% CI);

= 8.408, *p* = 0.00373, 95% CI);

= 8.589, *p* = 0.00338, 95% CI);

= 14.11, *p* = 0.0069, 95% CI).


**Table 16.** Results of the study: number of patients treated with topical steroids.


**Table 17.** Results of the study: severity index of the disease.


**Table 18.** Gender distribution versus severity index.

**Figure 9.** Gender distribution among patients involved in the study.

Our data support a male predominance in all forms of psoriasis (54.13% versus 45.87%) and greater severity in men (**Table 19**).

#### *2.3.1.2. Age of patients at the moment of clinical examination versus severity index*

**Type of psoriasis Nr. cases %** Severe (PASI > 10) 200 16.18 Moderate (PASI: 3/5–10) 500 40.45 Mild 536 43.37

**Psoriasis severity Gender of the patient Total Male Female** Mild 266 270 536 39.76% 47.62% Moderate 270 230 500 40.36% 40.56% Severe 133 67 200 19.88% 11.82% Total 669 567 1236

Total 1236

144 An Interdisciplinary Approach to Psoriasis

**Table 17.** Results of the study: severity index of the disease.

**Table 18.** Gender distribution versus severity index.

**Figure 9.** Gender distribution among patients involved in the study.

The mean (medium) age of patients presents important differences reported to the severity of the disease (*F* = 45.780, *p* ≪ 0.01, 95% CI) (**Figure 10**), with small values for mild cases (41.11 ± 16.07 SD) and greater values for severe cases (53.06 ± 13.82 SD) (**Table 20**).


**Figure 10.** Mean (medium) age of patients at the moment of clinical examination.

Psoriasis is a disease of all ages but predominant around 40 years of age; early psoriasis (manifesting before 40 years of age) is associated with increased severity index, while late psoriasis (manifesting after 40 years of age) appears to be milder (**Table 21**). We do not see the peak in the age groups 20–30 and 40–50, but there is a quite uniform distribution starting with the age group 20 and ending with age group 60 years old (**Figure 11**). The most active age group 30–50 years is affected by psoriasis (**Table 22**).


**Table 20.** Age of patients at the moment of clinical examination versus severity index.


**Table 21.** Test ANOVA—results.

**Figure 11.** Mean (medium) age of patients at the onset of disease.


**Table 22.** Results of the unequal N HSD test: correlations between age of patients and the severity index.

#### *2.3.1.3. Age of the patients at the onset of psoriasis versus severity index*

The first diagnosis of psoriasis was made at the age 10–30 for the most of the patients and the percentage of psoriasis de novo falls with age (**Table 23**). This could mean that majority of patients were diagnosed previously or they do not seek special care in the older age. Our findings suggest that there is a march over time toward greater severity in the disease.

The medium of age of onset shows statistical differences related to severity of psoriasis (*F* = 11.69, *p* = 0.000009, 95% CI): for mild forms were 27.15 ± 14.92 SD (**Table 24**), for moderate cases 29.95 ± 15.07 SD, and for severe cases 33.17 ± 15.07 SD (**Table 25**).


**Table 23.** Age of patients at the onset of psoriasis versus severity index.


#### **Table 24.** Test ANOVA—results.

Psoriasis is a disease of all ages but predominant around 40 years of age; early psoriasis (manifesting before 40 years of age) is associated with increased severity index, while late psoriasis (manifesting after 40 years of age) appears to be milder (**Table 21**). We do not see the peak in the age groups 20–30 and 40–50, but there is a quite uniform distribution starting with the age group 20 and ending with age group 60 years old (**Figure 11**). The most active age group

**Psoriasis Media age Media Dev.std Er.std Min Max** *Q***25 Median** *Q***75**

Severe 53.06 51.13 54.99 13.82 0.98 12.00 88.00 43.50 53.50 63.00 Moderate 45.79 44.47 47.11 15.01 0.67 13.00 91.00 34.00 45.00 57.00 Mild 41.11 39.74 42.47 16.07 0.69 6.00 89.00 29.00 40.00 52.00 All Groups 44.94 44.05 45.82 15.84 0.45 6.00 91.00 33.00 44.00 57.00

*F* **(95%** *confidence interval***)** *p*

30–50 years is affected by psoriasis (**Table 22**).

146 An Interdisciplinary Approach to Psoriasis

**Table 21.** Test ANOVA—results.

**−95% +95%**

**Figure 11.** Mean (medium) age of patients at the onset of disease.

**Table 20.** Age of patients at the moment of clinical examination versus severity index.

Levene Test of Homogeneity of Variances 3.034166 0.048474 Brown-Forsythe Test of Homogeneity of Variances 2.843525 0.058602 Test ANOVA 45.78075 0.000000


**Table 25.** Results of the unequal N HSD test: correlations between age of patients at the onset of psoriasis and the severity index.

## *2.3.1.4. Distribution of cases reported to residence/location versus severity index*

The present study confirms the higher prevalence of psoriasis in urban area, but mild cases were diagnosed compared with severe and untreated forms seen in people living in rural areas (**Figure 12**). Explanations can be found in reduced accessibility of people living in villages far away from a specialized medical center; long period of no treatments especially in milder forms considering the disease an esthetic problem rather than a disease; stress-less life, open air activity with many hours of sun bathing/exposure; different nutrition habits (less industrialized and processed food, less meat, and more vegetables), type of water, skin-care practices, tobacco, alcohol, smaller exposure to drugs, and other chemicals (**Table 26**).

Major association exists between index severity and residence of the patients (*r* = 0.319, *p* = 0.0037, *χ*<sup>2</sup> = 9.507, *p* = 0.0086, 95% CI). Although the prevalence of psoriasis is higher in urban area, mild cases are diagnosed, severe and untreated forms are seen in people living in rural areas (**Table 27**).

## *2.3.1.5. Level of education versus severity index*

High level of education was recognized in patients severely affected by psoriasis. Persons in worrying conditions were related to income/job such as retired people, with no income or social-assisted developed severe forms of psoriasis (**Table 28**).

**Figure 12.** Residence distribution among patients involved in the study.

#### Clinical and Epidemiological Factors Predicting the Severity of Psoriasis http://dx.doi.org/10.5772/intechopen.68728 149


**Table 26.** Residence versus severity index.

*2.3.1.4. Distribution of cases reported to residence/location versus severity index*

0.0037, *χ*<sup>2</sup>

areas (**Table 27**).

148 An Interdisciplinary Approach to Psoriasis

*2.3.1.5. Level of education versus severity index*

social-assisted developed severe forms of psoriasis (**Table 28**).

**Figure 12.** Residence distribution among patients involved in the study.

The present study confirms the higher prevalence of psoriasis in urban area, but mild cases were diagnosed compared with severe and untreated forms seen in people living in rural areas (**Figure 12**). Explanations can be found in reduced accessibility of people living in villages far away from a specialized medical center; long period of no treatments especially in milder forms considering the disease an esthetic problem rather than a disease; stress-less life, open air activity with many hours of sun bathing/exposure; different nutrition habits (less industrialized and processed food, less meat, and more vegetables), type of water, skin-care

practices, tobacco, alcohol, smaller exposure to drugs, and other chemicals (**Table 26**).

Major association exists between index severity and residence of the patients (*r* = 0.319, *p* =

area, mild cases are diagnosed, severe and untreated forms are seen in people living in rural

High level of education was recognized in patients severely affected by psoriasis. Persons in worrying conditions were related to income/job such as retired people, with no income or

= 9.507, *p* = 0.0086, 95% CI). Although the prevalence of psoriasis is higher in urban


**Table 27.** Results of the study: correlations between residence distribution and the severity index.


**Table 28.** Level of education versus severity index.

Level of education points out a strong correlation with severity (*r* = −0.413, *p* ≪ 0.01); patients with less than 12 years of school presented more cases with psoriasis type moderate-severe (**Table 29**). Although high educated persons, with university degree are more often diagnosed with psoriasis, cases are less severe.

Although higher education suggests a higher prevalence of psoriasis, a lower level of education correlates strongly with moderate-severe forms of psoriasis.

Education may be related to multiple confounding factors including alcohol intake, smoking, and access to specialized dermatological care.

## *2.3.1.6. Jobs distribution/income versus severity index*

Among pupils and students, the most frequently diagnosed form of psoriasis was mild one (66.48%), severe disease being reported to only 2.75%, while persons without any occupation presented severe psoriasis 24.16%, respectively, 24% (**Table 30**). Moderate forms were seen in retired persons (43.62%) and jobless (42.4%). Jobless patients had worse severity (*χ*<sup>2</sup> = 66.67, *p* ≪ 0.01, 95% CI) (**Table 31**).



**Table 29.** Results of the study: correlations between level of education and the severity index.

**Table 30.** Jobs distribution versus severity index.


**Table 31.** Results of the study: correlations between jobs distribution and the severity index.

#### *2.3.2. Correlations between clinical data and the severity index of psoriasis*

#### *2.3.2.1. Family history of psoriasis versus severity index*

Level of education points out a strong correlation with severity (*r* = −0.413, *p* ≪ 0.01); patients with less than 12 years of school presented more cases with psoriasis type moderate-severe (**Table 29**). Although high educated persons, with university degree are more often diagnosed

Although higher education suggests a higher prevalence of psoriasis, a lower level of educa-

Education may be related to multiple confounding factors including alcohol intake, smoking,

Among pupils and students, the most frequently diagnosed form of psoriasis was mild one (66.48%), severe disease being reported to only 2.75%, while persons without any occupation presented severe psoriasis 24.16%, respectively, 24% (**Table 30**). Moderate forms were seen in

= 66.67, *p*

retired persons (43.62%) and jobless (42.4%). Jobless patients had worse severity (*χ*<sup>2</sup>

**df = 12 Chi-square** *χ***<sup>2</sup>** *p* **(95%** *interval de încredere***)**

**Job Psoriasis severity Total Mild Moderate Severe**

Pupil/student 121 56 5 182

Employee 313 316 123 752

Retired 48 65 36 149

Social assisted 12 10 6 28

With no income 42 53 30 125

Total 536 500 200 1236

66.48% 30.77% 2.75%

41.62% 42.02% 16.36%

32.21% 43.62% 24.16%

42.86% 35.71% 21.43%

33.60% 42.40% 24.00%

Pearson Chi-square—*χ*<sup>2</sup> 77.51211 0.00000 M-L Chi-square 85.73127 0.00000 Correlation coefficient (Spearman Rank *R*) −0.4139638 0.00000

**Table 29.** Results of the study: correlations between level of education and the severity index.

tion correlates strongly with moderate-severe forms of psoriasis.

with psoriasis, cases are less severe.

150 An Interdisciplinary Approach to Psoriasis

≪ 0.01, 95% CI) (**Table 31**).

**Table 30.** Jobs distribution versus severity index.

and access to specialized dermatological care.

*2.3.1.6. Jobs distribution/income versus severity index*

There was a positive family history of psoriasis in 29.53% of subjects, 16.18% first-degree relatives, 9.30% second-degree, 2.91% third-degree, and 1.13% fourth-degree (**Table 32**).

A family history of psoriasis was associated with greater disease severity (*r* = −0.448, *χ*<sup>2</sup> = 18.32, *p* = 0.01893, 95% CI) (**Table 33**).

## *2.3.2.2. The distribution of (unique/multiple) psoriatic lesions at the moment of clinical inspection versus severity index*

The results (**Table 34**) prove the absence of an important correlation between the severity index and type of lesions at the onset of psoriasis (unique/multiple lesions) (*r* = 0.0249, *p* = 0.381, 95% CI) (**Table 35**). One can notice that in 19.27% cases of severe psoriasis, patients describe multiple lesions at the first diagnosis (**Figure 13**).

#### *2.3.3. Correlations between comorbidities and the severity index of psoriasis*

#### *2.3.3.1. Presence of general comorbidities versus index severity*

Comorbidities were present in 36.1% of patients with mild form of psoriasis, 44.05% with moderate forms, and in 19.64% of severe psoriasis (**Figure 14**, **Table 36**).


**Table 32.** Results of the study: family history versus severity index.


**Table 33.** Results of the study: correlations between family history and the severity index.


**Table 34.** Results of the study: distribution of psoriatic lesion(s) versus severity index.


**Table 35.** Correlations between the distribution of (unique/multiple) psoriatic lesions and the severity index.

The results (*r* = 0.41, *χ*<sup>2</sup> = 18.79, *p* = 0.00008, 95% CI) confirm a strong association between the presence of comorbidities and severity of psoriasis (**Table 37**).

#### *2.3.3.2. Comorbidities: appendectomy versus index severity*

Appendectomy (**Table 38**, **Figure 15**) does not correlate with severity index of psoriasis (*r*= −0.0096, *χ*<sup>2</sup> =0.967, *p* = 0.616, 95% CI) (**Table 39**).

*2.3.4. Correlations between evolution characteristics and the severity index of psoriasis*

#### *2.3.4.1. Risk factors: alcohol consumption versus index severity*

Severe forms of psoriasis were found in patients with declared chronic alcohol intake (21.22%), while mild forms were depicted within non-consumers (47.94%) (**Table 40**, **Figure 16**).

**Figure 13.** The distribution of (unique/multiple) psoriatic lesions among patients involved in the study.

**Figure 14.** The distribution of comorbidities among patients involved in the study.

The results (*r* = 0.41, *χ*<sup>2</sup>

152 An Interdisciplinary Approach to Psoriasis

(*r*= −0.0096, *χ*<sup>2</sup>

presence of comorbidities and severity of psoriasis (**Table 37**).

Pearson Chi-square—*χ*<sup>2</sup> 0.9511274 0.62154 M-L Chi-square 0.9196143 0.63141 Correlation coefficient (Spearman Rank *R*) 0.0249217 0.38135

**Table 34.** Results of the study: distribution of psoriatic lesion(s) versus severity index.

**Psoriasis severity Onset location of psoriasis Total**

**Table 33.** Results of the study: correlations between family history and the severity index.

Pearson Chi-square—*χ*<sup>2</sup> 18.32477 0.01893 M-L Chi-square 19.13866 0.01414 Correlation coefficient (Spearman Rank *R*) −0.44809 0.011536

Mild 492 44 536 43.66% 40.37% Moderate 456 44 500 40.46% 40.37% Severe 179 21 200 15.88% 19.27% Total 1127 109 1236

**Unique location Multiple locations**

**df = 8 Chi-square** *χ***<sup>2</sup>** *p* **(95%** *confidence interval***)**

=0.967, *p* = 0.616, 95% CI) (**Table 39**).

*2.3.4. Correlations between evolution characteristics and the severity index of psoriasis*

*2.3.3.2. Comorbidities: appendectomy versus index severity*

*2.3.4.1. Risk factors: alcohol consumption versus index severity*

= 18.79, *p* = 0.00008, 95% CI) confirm a strong association between the

Appendectomy (**Table 38**, **Figure 15**) does not correlate with severity index of psoriasis

**df = 2 Chi-square** *χ***<sup>2</sup>** *p* **(95%** *confidence interval***)**

**Table 35.** Correlations between the distribution of (unique/multiple) psoriatic lesions and the severity index.

Severe forms of psoriasis were found in patients with declared chronic alcohol intake (21.22%), while mild forms were depicted within non-consumers (47.94%) (**Table 40**, **Figure 16**).


**Table 36.** Results of the study: comorbidities versus severity index.


**Table 37.** Correlations between comorbidities and severity index.


**Table 38.** Results of the study: (comorbidities) appendectomy versus severity index.

Statistically, a correlation between alcohol intake and index severity is proved (*r* = −0.48, *χ*<sup>2</sup> = 24.30, *p* ≪ 0.01, 95% CI) (**Table 41**).

#### *2.3.4.2. Risk factors: smoking versus index severity*

Smokers are prone to severe forms of psoriasis (17.7%), and non-smokers with less severe ones (**Table 42**, **Figure 17**).

Smoking and severity of psoriasis highly correlate (*r* = 0.254, *χ*<sup>2</sup> = 10.49, *p* = 0.00527, 95% CI) (**Table 43**).

**Figure 15.** Number of patients with appendectomy among patients involved in the study.


**Table 39.** Correlations between number of patients with appendectomy and severity index.


**Table 40.** Results of the study: alcohol consumption versus severity index.

Statistically, a correlation between alcohol intake and index severity is proved (*r* = −0.48, *χ*<sup>2</sup>

**Psoriasis severity Comorbidities Total Absent Present** Mild 353 183 536 48.22% 36.31% Moderate 278 222 500 37.98% 44.05% Severe 101 99 200 13.80% 19.64% Total 732 504 1236

**Psoriasis severity Appendectomy Total Present Absent** Mild 106 430 536 41.57% 43.83% Moderate 110 390 500 43.14% 39.76% Severe 39 161 200 15.29% 16.41% Total 255 981 1236

Pearson Chi-square—*χ*<sup>2</sup> 18.79107 0.00008 M-L Chi-square 18.86543 0.00008 Correlation coefficient (Spearman Rank *R*) 0.4108901 0.00001

**df = 2 Chi-square** *χ***<sup>2</sup>** *p* **(95%** *confidence interval***)**

**Table 36.** Results of the study: comorbidities versus severity index.

154 An Interdisciplinary Approach to Psoriasis

**Table 37.** Correlations between comorbidities and severity index.

Smokers are prone to severe forms of psoriasis (17.7%), and non-smokers with less severe

24.30, *p* ≪ 0.01, 95% CI) (**Table 41**).

ones (**Table 42**, **Figure 17**).

(**Table 43**).

*2.3.4.2. Risk factors: smoking versus index severity*

Smoking and severity of psoriasis highly correlate (*r* = 0.254, *χ*<sup>2</sup>

**Table 38.** Results of the study: (comorbidities) appendectomy versus severity index.

=

= 10.49, *p* = 0.00527, 95% CI)

#### *2.3.5. Multivariable analysis of factors implicated in severity of psoriasis*

In multivariate analysis, age at the moment of clinical examination (*r* **= 0.83**, *p* ≪ 0.01), age of onset (*r* **= −0.69**, *p* = 0.000053, 95% CI), education level (*r* **= −0.588**, *p* = 0.0037), residence (*r* **= 0.688**, *p* = 0.0156, 95% CI), job (*r* **= 0.671**, *p* = 0.0328, 95% CI), gender (*r* **= −0.45**, *p* = 0.0394, 95% CI), and smoking (*r* **= 0.597**, *p* = 0.044, 95% CI) were significant factors associated with severity of psoriasis (**Table 44**).

**Figure 16.** Alcohol consumption among patients involved in the study.


**Table 41.** Correlations between alcohol consumption and severity index.


**Table 42.** Results of the study: smoking versus severity index.

**Figure 17.** Smoking among patients involved in the study.

**Figure 16.** Alcohol consumption among patients involved in the study.

156 An Interdisciplinary Approach to Psoriasis

**Table 41.** Correlations between alcohol consumption and severity index.

**Table 42.** Results of the study: smoking versus severity index.

**df = 2 Chi-square** *χ***<sup>2</sup>** *p* **(95%** *confidence interval***)**

Pearson Chi-square—*χ*<sup>2</sup> 24.30044 0.00001 M-L Chi-square 24.36224 0.00001 Correlation coefficient (Spearman Rank *R*) −0.489582 0.000

**Psoriasis severity Smoking Total Nonsmoker Smoker** Mild 414 122 536 46.15% 35.99% Moderate 343 157 500 38.24% 46.31% Severe 140 60 200 15.61% 17.70% Total 897 339 1236


**Table 43.** Correlations between smoking and severity index.



**Table 44.** Multivariable analysis of factors implicated in severity of psoriasis.

## **3. Conclusion**

Our study has several strengths.

First of all, the study includes a high number of patients with psoriasis followed over a period of 8 years: 1236 persons were enrolled in the study.

Second, over a period of 8 years, detailed and updated information regarding a large variety of factors throughout the cohort follow-up was collected, thus allowing data correlation between psoriasis and various factors and/or different comorbidities.

Third, correlation between psoriasis and different factors permitted the investigation of potential associations over long durations such as the analysis of the association of psoriasis with several different comorbidities, demographic data, psoriasis severity.

Some limitations of this study include the following: it was performed only on Caucasians from predominantly the same region in Romania; therefore, generalizing the results to other ethnicities may be partial.

The study was conducted in an outpatient clinic specialized for psoriasis over a period of 8 years, so an increased number of patients diagnosed with psoriasis earlier had to self-report medical history with a small proportion of missing data. Despite this retrospective characteristic, the recall and the high completion rate for all questions on psoriasis were highly accurate.

Psoriasis is a common chronic systemic disease (not a simple skin disorder), spread worldwide, with a reported prevalence varying from 0.09 to 11.43% [39]. Psoriasis can touch any age, with a great variability: from 6 to 91 years old. The number of years should not be a reason for medical advice restriction.

This complex disease, with unknown cause, has many trigger factors, unpredictable course, severe comorbidities, and a great impact on quality of life. Further research is needed to identify these comorbidities and to take into consideration when evaluating the burdens of psoriasis such as costs, impact on quality of life, and integration of psoriatic patient in the society,therefore to be able to recommend the best management and treatment.

## **Author details**

Anca Chiriac1 , Cristian Podoleanu2 \* and Doina Azoicai3

\*Address all correspondence to: podoleanu@me.com

1 University of Medicine and Pharmacy "Grigore T. Popa", Iasi, Romania

2 Cardiology Department, University of Medicine and Pharmacy of Târgu Mureș, Targu Mures, Romania

3 Epidemiology Department, University of Medicine and Pharmacy "Grigore T. Popa", Iasi, Romania

## **References**

**3. Conclusion**

**Partial correlation**  *psoriasis severity* **versus**

158 An Interdisciplinary Approach to Psoriasis

Our study has several strengths.

ethnicities may be partial.

son for medical advice restriction.

of 8 years: 1236 persons were enrolled in the study.

**Confidence interval (Beta)**

**Table 44.** Multivariable analysis of factors implicated in severity of psoriasis.

between psoriasis and various factors and/or different comorbidities.

with several different comorbidities, demographic data, psoriasis severity.

First of all, the study includes a high number of patients with psoriasis followed over a period

Location 0.68837 0.028427 0.3510 0.05579 2.42157 0.015611 Family history −0.013668 0.028332 −0.01158 0.02400 −0.48244 0.629586 Comorbidities −0.034033 0.028512 −0.00023 0.00019 −1.19362 0.232876 Alcohol −0.052250 0.033016 −0.8041 0.05081 −1.58256 0.113803 Smoking 0.59732 0.029716 0.9691 0.04821 2.01006 0.044662

**Std.Err. (Beta)** *B* **Std.Err. B** *t p* **(95%** *confidence* 

*interval***)**

Second, over a period of 8 years, detailed and updated information regarding a large variety of factors throughout the cohort follow-up was collected, thus allowing data correlation

Third, correlation between psoriasis and different factors permitted the investigation of potential associations over long durations such as the analysis of the association of psoriasis

Some limitations of this study include the following: it was performed only on Caucasians from predominantly the same region in Romania; therefore, generalizing the results to other

The study was conducted in an outpatient clinic specialized for psoriasis over a period of 8 years, so an increased number of patients diagnosed with psoriasis earlier had to self-report medical history with a small proportion of missing data. Despite this retrospective characteristic, the recall and the high completion rate for all questions on psoriasis were highly accurate. Psoriasis is a common chronic systemic disease (not a simple skin disorder), spread worldwide, with a reported prevalence varying from 0.09 to 11.43% [39]. Psoriasis can touch any age, with a great variability: from 6 to 91 years old. The number of years should not be a rea-

This complex disease, with unknown cause, has many trigger factors, unpredictable course, severe comorbidities, and a great impact on quality of life. Further research is needed to identify these comorbidities and to take into consideration when evaluating the burdens of psoriasis such as costs, impact on quality of life, and integration of psoriatic patient in the

society,therefore to be able to recommend the best management and treatment.


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