Psoriasis is a common, genetically determined chronic papulosquamous inflammatory condition of the skin and joint, characterised by presence of sharply demarcated dull red scaly plaques, particularly on the extensor aspects of limbs and on the scalp. The disease enormously varies in duration, extent and affects 1-2% of general population.1

Psoriasis affects the patient both psychologically and economically. It also impacts the patient’s relationship, confidence, social behaviour and may lead to depression creating feelings of hopelessness and loss of desire.

The Dermatology Life Quality Index (DLQI) is a simple, reliable, validated 10-item questionnaire covering six dimensions (symptoms and feelings, daily activities, leisure, work and school, personal relationships and treatment) that is used to assess the impact of disease on the quality of life of an affected person and current treatments on the patient's well-being. The DLQI is calculated by summing the score of each question resulting in a maximum of 30 and a minimum of 0. Each question has four possible responses, with higher scores representing a poor QOL.2

Many scales exist for measuring the severity of psoriasis. The degree of severity is generally based on proportion of body surface area affected, disease activity, response to previous therapy and the impact of the disease on the person. The psoriasis area severity index (PASI) is the most commonly used measurement tool for severity of psoriasis.

It is very important to evaluate quality of life of psoriasis patients and also screen the patients for associated psychiatric comorbid conditions like anxiety and depression, before making therapeutic decision. Assessment of QOL along with PASI score will help in proper selection of suitable treatment options also help in rationalizing the cost benefit ratio.   

MATERIALS AND METHODS

The present study was conducted by recruiting 154 patients of chronic plaque psoriasis attending our department of Dermato-Venereo-Leprology from December 2016 to August 2018. Approval from the institutional ethics committee was sought. All patients were counselled about the study and informed written consent was obtained. Inclusion criteria comprised all newly diagnosed cases as well as old cases of chronic plaque psoriasis above 18 years age and patients who were handicapped, pregnant or having other chronic debilitating diseases were excluded from the study. Relevant history, clinical examination and necessary investigations along with PASI were done for all the patients. In our study: PASI<7 was graded as mild; 7-12 was graded as moderate, >12 was graded as severe.3 Socioeconomic status was assessed by modified BG Prasad scale (January 2017). Copy right permission, for the use of DLQI scale in our study was taken by Dr. A. Y. Finlay, Professor and HOD Department Of Dermatology, University of medicine Cardiff, Wales, U.K.

Statistical analysis:

Correlation of DLQI with age of onset, duration of disease, PASI score and also between PASI score and DLQI was assessed by calculating Pearson’s correlation coefficient (r-value). Spearman’s correlation coefficient (rho) was used to assess correlation of DLQI with socioeconomic status and education status. One-way ANOVA was used to compare DLQI in different categories of pruritus and occupation status. P < 0.05 was considered as statistically significant. Statistical software STATA version 14.0 was used for data analysis.

Psoriasis is a common, genetically determined chronic papulosquamous inflammatory condition of the skin and joint, characterised by presence of sharply demarcated dull red scaly plaques, particularly on the extensor aspects of limbs and on the scalp. The disease enormously varies in duration, extent and affects 1-2% of general population.1

Psoriasis affects the patient both psychologically and economically. It also impacts the patient’s relationship, confidence, social behaviour and may lead to depression creating feelings of hopelessness and loss of desire.

The Dermatology Life Quality Index (DLQI) is a simple, reliable, validated 10-item questionnaire covering six dimensions (symptoms and feelings, daily activities, leisure, work and school, personal relationships and treatment) that is used to assess the impact of disease on the quality of life of an affected person and current treatments on the patient's well-being. The DLQI is calculated by summing the score of each question resulting in a maximum of 30 and a minimum of 0. Each question has four possible responses, with higher scores representing a poor QOL.2

Many scales exist for measuring the severity of psoriasis. The degree of severity is generally based on proportion of body surface area affected, disease activity, response to previous therapy and the impact of the disease on the person. The psoriasis area severity index (PASI) is the most commonly used measurement tool for severity of psoriasis.

It is very important to evaluate quality of life of psoriasis patients and also screen the patients for associated psychiatric comorbid conditions like anxiety and depression, before making therapeutic decision. Assessment of QOL along with PASI score will help in proper selection of suitable treatment options also help in rationalizing the cost benefit ratio.   

MATERIALS AND METHODS

The present study was conducted by recruiting 154 patients of chronic plaque psoriasis attending our department of Dermato-Venereo-Leprology from December 2016 to August 2018. Approval from the institutional ethics committee was sought. All patients were counselled about the study and informed written consent was obtained. Inclusion criteria comprised all newly diagnosed cases as well as old cases of chronic plaque psoriasis above 18 years age and patients who were handicapped, pregnant or having other chronic debilitating diseases were excluded from the study. Relevant history, clinical examination and necessary investigations along with PASI were done for all the patients. In our study: PASI<7 was graded as mild; 7-12 was graded as moderate, >12 was graded as severe.3 Socioeconomic status was assessed by modified BG Prasad scale (January 2017). Copy right permission, for the use of DLQI scale in our study was taken by Dr. A. Y. Finlay, Professor and HOD Department Of Dermatology, University of medicine Cardiff, Wales, U.K.

Statistical analysis:

Correlation of DLQI with age of onset, duration of disease, PASI score and also between PASI score and DLQI was assessed by calculating Pearson’s correlation coefficient (r-value). Spearman’s correlation coefficient (rho) was used to assess correlation of DLQI with socioeconomic status and education status. One-way ANOVA was used to compare DLQI in different categories of pruritus and occupation status. P < 0.05 was considered as statistically significant. Statistical software STATA version 14.0 was used for data analysis.

Out of total 154 patients, 102 patients (66.23%) were males whereas 52 patients (33.77%) were females. Majority of the patients (29.2%) were in the age group of 41-50 years followed by 27.3% in the age group of 31-40 years. There was no statistically significant correlation of DLQI with age (P = 0.4838). Eleven patients (7.1%) had a family history of psoriasis.

In our study, 24.7% patients were unskilled workers followed by housewives (22.1%), skilled workers (18.8%) and clerical/shopkeeper/farmers (12.5%). There was no statistical significant correlation between DLQI and occupation status (P =0.3269). Out of 154 patients, 36 had primary school education (23.4%), 30 were graduate/postgraduate (19.5%), 29 had secondary school education (18.8%), 27 had higher secondary education (17.5%) and 26 were illiterate (16.9%). There was statistical significant correlation between DLQI and education status (P= 0.0207). In our study, majority of patients belonged to middle class (33.8%) followed by upper middle (22.1%), lower middle (21.4%), upper (16.9%) and lower class (5.8%) according to modified BG Prasad scale (January 2017). There was no statistical significant correlation between DLQI and monthly family income per capita (p = 0.3269) (Table-1).

Table 1- Sociodemographic variables and it’s comparison with DLQI scor

N= Number of patient, †SD= standard deviation, ‡Rho= correlation coefficient, §Kw= Kruskall Wallis statistics, ‖NS= not significant,

25.3% of the patients complained of joint pain and 99.4% of the patients complained of pruritus, of which 50% had mild pruritus, 42.9% had moderate pruritus and 6.50% had severe pruritus. There was statistically highly significant correlation between DLQI and pruritus (P<0.001). 80 (52.0%) and 13 (8.4%) patients had history of psoriasis exacerbations in winter and summer respectively.

The mean age at presentation was 43.45 years (SD ± 11.26 years), 45.74 years for male (SD ± 11.96 years) and 39.17 for female patients (SD ± 8.32 years). Highly significant difference is observed between males and females with respect to age at presentation of patients (P < 0.001). The mean age of psoriasis onset was 37.32 years (SD ± 11.53 years), 34.09 years for male (SD ± 10.75 years) and 39 years for female patients (SD ± 11.67 years) (Table-2). The duration of psoriasis in our patients were less than 1 year in 34.4%, 3-5 years in 16.9%, 5-10 years in 16.9%, 1-3 year in 14.9%, 10-20 years in 10.4% and more than 20 years in 6.5%. There was no statistical significant correlation between DLQI and duration of disease.

Table 2 - Demographic and clinical characteristics of the study patient

The mean PASI was 8.14 for male patients (SD ± 6.28) and 4.50 for female patients (SD ± 4.50) (Table-2). There was highly significant difference in PASI score in males and females (P<0.001). We observed that women have less severe psoriasis compared with men. 65.6% patients had mild psoriasis (PASI<7), 17.5% of patients had psoriasis of moderate severity (PASI 7-12) while 16.9% had severe psoriasis (PASI>12). There was highly significant correlation between PASI and overall DLQI (r = 0.7683, P = <0.0001).

Nail involvement was observed in 86 (55.8%) patients, among these 67 (65.7%) were males and 19 (36.5%) were females. Highly significant difference is observed between males and females with respect to nail involvement (P = 0.001). Pitting (47.4%) was the most common nail change, followed by subungual hyperkeratosis (20.8%) and longitudinal ridging (11.0%) (Table-3). There was statistical highly significant correlation between DLQI and patients with nail changes (P = 0.0097). According to this study, lower limbs (35.7%) and scalp (35.7%) were the most common initial site affected. 

Table 3- Domains of quality of life affected in psoriasis patients

                   *r= correlation coefficient, p value<0.05= significant

The mean DLQI was 3.58 for male patients (SD ± 3.07) and 2.96 for female patients (SD ± 2.69) (Table-2). There was no statistically significant correlation for DLQI with sex (P = 0.0793). Symptom and feeling (99.4%) was the most commonly affected domain, followed by treatment (35.7%), daily activity (14.9%), work and school (12.3%), leisure (11%) and personal relationship (6.5%) (Table-3). All domains of QOL showed highly significant positive correlation with PASI (Figure-1). There was no significant difference in the domain of quality of life affected in males and females except for leisure which was more affected in men compare to females (P = 0.042). Psoriasis had small effect on quality of life in 72.7% of the patients, no effect on 15.6% of patients, moderate effect on 7.8% of patients and very large effect on 3.3% of patients (Table-4).

Table 4- Effect of psoriasis on the quality of life of patients

Quality of life (QOL) is a concept incorporating all factors that impact on an individual's life. Good QOL is present when "the hopes of an individual are matched by experience". QOL has been divided into several components, such as psychological, social and physical domains.

In our study, There was highly significant correlation between PASI and overall DLQI (r = 0.7683, P = <0.0001). Increase in the PASI score was associated with increased effect on quality of life, which correlated with studies by Nayak et al, Gazi et al, Finley et al, Rakhesh et al and Aghaei et al. while this finding of our study did not correlate with study conducted by Vettuparambil et al, Yang et al, and Fortune et al.4-11 these studies did not observed significant correlation between PASI and quality of life.

We observed majority of patients (72.7%) of psoriasis had small effect on quality of life” which did not correlate with Gazi et al5, Vettuparambil et al9 and Manjula et al12 studies (these studies showed psoriasis had moderate to severe effect on quality of life). Its might be due to different PASI grading score used by these studies and subjective nature of the DLQI and PASI. In a study by Vettuparambil et al., Thirty-three (67.3%) patients had marked (moderate or above) impact on overall QOL. Manjula showed that the QOL was affected in 75% of which 9.4% were mild (score < 9), 31.2% were moderate (score 10–18) and 34.4% were severe (score > 18). In a study by Gazi et al., patients indicated “no effect at all” (3.84%), “slight effect” (23.07%), “moderate effect” (25%), “very large effect” (32.69%), and “extremely large effect (15.38%)” respectively on their life.

 In our study, all domains of QOL showed highly significant positive correlation with PASI. Symptom and feeling (99.4%) was the most commonly affected domain, followed by treatment (35.7%), daily activity (14.9%), work and school (12.3%), leisure (11%) and personal relationship (6.5%). These findings correlates with study conducted by Gazi et al5, Vettuparambil et al9 and Manjula et al.12 In a study by Vettuparambil et al., Among the various

domains of QOL, symptoms and feeling were found to be affected most, followed by work and school, and daily activities. In a study by Manjula et al., among the PDI subsets, daily activities were affected the most (90.6%), followed by work (84.4%), leisure activities (71.9%), problems with treatment (68.7%) and the least affected was personal relations (62.5%). In a study by Gazi et al., The section for symptoms and feelings had the highest score while the section for work and school had the lowest score.

There was statistical significant correlation between DLQI and education status (p=0.0207). We observed an increase in the impairment of QOL of illiterate and those who had lower education compare to higher education, as seen in study conducted by chakmur et al13 while this finding of our study did not correlate with study conducted by Vettuparambil et al.9 In a study by Vettuparambil et al., 49% had primary school education, 24.5% had secondary school education, 14.3% had higher secondary education (17.5%), 6.1% were illiterate and 4.1% had professional education. According to chakmur the mean DLQI score were 12.04 in primary-secondary school graduates and 10.58 in high school-university graduates.

There was statistical highly significant correlation between DLQI and patients with nail changes (P = 0.0097). Patients with nail psoriasis scored significantly higher mean scores on the DLQI (3.70 vs. 2.95, P = 0.0097), which correlated with studies conducted by chakmur et al13 and Petraskiene et al.14 according to chakmur the mean DLQI score was 12.61 in patients with nail involvement and 10.83 in patients without nail involvement. According to petraskiene , a large or an extremely large effect on the quality of life (DLQI>10 points) was by about 2 times more common in patients with nail psoriasis than in those without nail involvement.

There was statistically highly significant correlation between DLQI and pruritus (P<0.001). DLQI was found to be higher in patients who had moderate to severe grade pruritus. This finding correlates with study conducted by Kataria et al15 and Hayta et al.16 According to kataria pruritus had small effect on quality of life in 37% patients, moderate effect on 15% patients and severe effect on 47.5% patients.

We did not found statistical significant correlation between DLQI and monthly family income per capita (p = 0.1980), age (P = 0.4838), sex (P = 0.0793), occupation status (P =0.3269) and duration of disease (P = 0.6026).

Our study had few limitations. The study sample cannot be considered representative of general population because it is a single hospital-based study. Other limitation of our study is the subjective nature of the DLQI and PASI. 

Psoriasis can impair the quality of life (QOL) of affected patients. Various aspects of daily living such as social interactions, looking after one's household, job, work and schooling, feelings, leisure, personal relationship can be affected by the disease. The cost and time required for treatment can worsen the QOL. Quantification of the impact of psoriasis on the QOL, along with clinical severity assessment, could provide a measure of the clinical efficacy of the dermatological therapies and improvement in the overall psycho-social morbidity associated with the disease considered as a favourable treatment.

Conclusions and implications: Psoriasis has a negative impact on physical, emotional and psychological wellbeing of the affected patients, thus affecting patient’s Quality of life. There is a significant correlation between disease severity and the QOL. Patients with severe psoriasis have a reduction in quality of life and work productivity. Psoriasis patients with severe disease require a more holistic treatment approach that encompasses both medical and psychological measure.

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