¹Associate Professor, Department of Dermatology Venereology and Leprosy, Melmaruvathur Adhiparasakthi Institute of Medical Sciences and Research, Melmaruvathur, Tamilnadu- 603319, INDIA.

²Associate Professor, Department of Community Medicine, Chettinad Hospital and Research Institute, Chettinad Academy of Research and Education, Kelambakkam, Chennai, Tamil Nadu-603103. INDIA.

Email: suganthikandaswamy@gmail.com

RESULTS

140 patients with confirmed diagnosis of psoriasis were considered for present study. prevalence of psoriasis at our dermatology OPD was 2.17 %. Majority of patients were from 31-45 years age group (47.86 %) followed by 19-30 years age group (31.43 %). Male predominance was noted (63.57 %) with male to female ratio as 1.74:1.

Table 1: Distribution of Age and Gender.

               On the basis of history and clinical examination psoriasis vulgaris (72.14%) was most common diagnosis followed by palmoplantar psoriasis (13.57%), scalp psoriasis (9.29%). Less common types were nail psoriasis (2.14%), generalized pustular psoriasis (1.43%), psoriatic arthropathy (0.71%) and distal interphalangeal psoriatic arthropathy (0.71%),

Table 2: Diagnosis

In present study common co-morbidities noted in psoriasis patients were diabetes mellitus (51.43%), hypertension (49.29%), dyslipidemia (36.43%), metabolic syndrome (35.00%) and depression (25.71%).

Table 3: Co-morbidities in study patients

Alcohol consumption (35 %) was most common aggravating factors noted followed by stress such as lack of sleep, emotional stress, acute infection (32.86%), Smoking (22.14%), long exposure to air conditioning / cold weather (15.71%). Less common aggravating factors noted were drugs (beta-blockers, nonsteroidal anti-inflammatory drugs) (7.86%), physical trauma (2.86%), changes during pregnancy (2.86%) and oral contraceptive pills (1.43%),

Table 4: Aggravating factors noted

DISCUSSION

The onset of psoriasis can be at any time of life and it usually persists for life with relapses intermittently. The majority of cases, approximately 75%, present before the age of 40 years, with a peak at 20–30 years old. The remaining cases present after the age of 40 years. Patients with early disease onset tend to have a positive family history of psoriasis, frequent association with histocompatibility antigen (HLA)-Cw6, and more severe disease.⁵Bhandari et al.,⁶ noted male pre-dominance (65%) and majority of patients were between 30-50 years of age. Similar findings were noted in present study. Psoriasis predominantly affects the skin with erythematous plaques and adherent silvery white scales involving mainly the extensor surfaces of the body like scalp, back, elbows, knees etc.⁷In a Malaysian study⁷ with 15,794 patients, mean age onset of psoriasis was 35.14 ± 16.16 years. Male to female ratio was 1.3: 1. 23.1% of patients had positive family history of psoriasis. The most common clinical presentation was chronic plaque psoriasis (85.1%), followed by guttate psoriasis (2.9%), erythrodermic psoriasis (1.7%), and pustular psoriasis (1.0%). Majority of our patients (76.6%) had a mild disease with BSA < 10%. 57.1% of patients had nail involvement, while arthropathy was seen in 13.7% of patients. Common triggers of the disease include stress (48.3%), sunlight (24.9%), and infection (9.1%). Comorbidities observed include obesity (24.3%), hypertension (25.6%), hyperlipidemia (18%), diabetes mellitus (17.2%), ischemic heart disease (5.4%), and cerebrovascular disease (1.6%). Similar findings were noted in present study. Sekar S⁸ studied 40 patients diagnosed with moderate to severe plaque type of psoriasis. Mean age was 37.43±10.1 years and 55 % were males. The mean duration was 8.93 years and 15% had family history. The mean age of onset was earlier in the females (20.23 years) with a positive family history, as compared to males (25.36 years). About 62.5% had moderate psoriasis and 37.5% had severe psoriasis. At the baseline the PASI score was 31.98±6.08 and DLQI score was 36. About 67.5% had nail changes and 10% had psoriatic arthritis. Almost in half (47.5%) the duration of the disease was 1 to 5 years and scalp (32.5%) the most common initial site of involvement. In a retrospective study by Kumaraswamy SKA et al.,⁹ majority of the patients were in the age group 35-64 years (68%) and nearly 80 % of them were men. The most common type of psoriasis was Psoriasis vulgaris. More than half of the patients had severe type of psoriasis according to PASI scoring. 58 % of cases were repeat cases. Most common category of drugs administered were antihistaminic, corticosteroids, antibiotics, emollients and antimetabolites in that order. Hypertension was found among 16 % of patients. Serum albumin and total protein was found to be low in 52% and 27% of the patients respectively. Chronic plaque‑type psoriasis is the most common morphologic presentation of psoriasis, accounting for more than 90% of all cases.^7,10 Other morphologic variants that deserve special mention include palmoplantar psoriasis, pustular psoriasis, and recalcitrant psoriasis. For epidemiologic purposes, psoriasis can be classified into early and late onset psoriasis.⁷Psoriasis has been reported to be associated with metabolic disorders including obesity, dyslipidemia and diabetes.¹¹ Belliappa PR¹² studied 120 patients diagnosed with psoriasis vulgaris and prevalence of various comorbidities was: central obesity (58.3%), hypertension (46.79%), dyslipidemia (43.3%), diabetes mellitus (26.7%), metabolic syndrome (25%), ischemic heart disease (5%) and stroke (2.4%). Prevalence of metabolic syndrome was more in patients who had longer mean disease duration of psoriasis. Several risk factors/triggers participated in the etiology of psoriasis are described as trauma (Koebner phenomenon), preceding or concurrent streptococcal infection, particularly of the throat, hormonal factors (in females, peak around puberty, changes during pregnancy and provocation of psoriasis by high dose estrogen therapy) potentially indicate a role for hormonal factors), Stress is the most common etiological factor and patients with chronic disorders like Crohn’s disease are more likely to suffer from psoriasis.^13,14 Drugs that appear to have a strong causal relationship to psoriasis are beta-blockers, lithium, synthetic antimalarials, nonsteroidal anti-inflammatory drugs (NSAIDs), and tetracyclines.¹⁵ While hot and sunny may help clear psoriasis, air conditioning can dry out the skin and aggravate psoriasis. Similar findings were noted in present study. Alcohol and smoking: It has long been suspected that both cigarettes and alcohol have a detrimental effect on psoriasis. Increased alcohol consumption is a recognized stress response. Excess drinking is undoubtedly also a consequence of disease and leads to treatment resistance and reduces therapeutic compliance.¹⁶ Disfiguration, disability and marked loss of productivity are common challenges for people with psoriasis. There is also a significant cost to mental well-being, such as higher rates of depression, leading to negative impact for individuals and society.¹⁷ With the increasing prevalence and awareness of psoriasis and its association with various co-morbidities, there is ongoing need for research on various aspects of this disease related to epidemiology, etiopathogenesis, management, co-morbidities, impact on quality of life, economic and societal burden and healthcare costs.¹⁸

CONCLUSION

Common aggravating factors for psoriasis were alcohol consumption, stress, smoking and exposure to air conditioning/cold weather were noted. Various co-morbidities such as diabetes mellitus, hypertension, dyslipidemia, metabolic syndrome and depression were also noted. For management of psoriasis, dermatologists should adopt a multidisciplinary approach as screening for comorbid conditions, avoidance of aggravating factors and medications for appropriate control of psoriasis.

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