IMPACT OF PSORIASIS ON QUALITY OF LIFE IN EASTERN PROVINCE, SAUDI ARABIA

Ali Ahmed Alabdullah 1,3 , Mousa Jafar Alhaddad 2,3 , Yousef Ahmed Alabdullah 1,3 , Ali Mohammed Aljafar 1,3 , Mohammed Saleh Alhaddad 1 , Hassan Ali Alnasser 1 , Ahmed Eissa Aleissa 1 , Fatimah Hassan Alturaifi 1 , Esra Omar Alakloby 2 , Manar Mutlag Alharthi 2 , Lama Ibrahim Aloraini 1 and Omar Mohammed Alakloby 4 . 1. Medical Intern, Imam Abdulrahman bin Faisal University, Saudi Arabia. 2. Medical Student, Imam Abdulrahman bin Faisal University, Saudi Arabia. 3. These authors contributed equally to this work as the co-first authors. 4. Professor of Dermatology, King Fahd Hospital of the University, Imam Abdulrahman bin Faisal University, Dammam, Saudi Arabia. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History


ISSN: 2320-5407
Int. J. Adv. Res. 5 (12), 456-462 457 Introduction:-Psoriasis is a chronic lifelong inflammatory skin disease that is estimated to affect about 2% of the population worldwide. (Stern et al., 2004;Gelfand et al., 2005) In Saudi Arabia, it is the most frequent papulosquamous disorder accounting for 1.5% to 5.3% of all newly diagnostic cases of skin diseases. (Shelleh and Al-Hatit, 2004;Alakloby, 2005) Doctors and patients differ in their assessments of severity of this disease because doctors focus on the severity of skin lesions and the response to therapy. (Krueger et al., 2000;Finlay, 2005) From the patient's point of view, on the other hand, psoriasis is considered severe if it causes embarrassment or anxiety, if it affects relationships and everyday activities such as work, study, or sport, or if it causes disability as a result of joint involvement. (Finlay, 2005) Psoriasis is also associated with lack of self-esteem, an increased prevalence of depression and a greater likelihood of suicide. (Krueger et al., 2001;Golpour et al., 2012;Singh et al., 2017) Thus, the impact on quality of life (QoL) represents an important assessment measure of the severity of this chronic disease. It is therefore crucial that dermatologists include QoL measurements when they monitor the progress of psoriasis patients as the QoL of such patients may be underestimated by objective assessments of clinical severity. (Krueger et al., 2000;Finlay and Kelly, 1987) The impact of psoriasis on the quality of life might differ between countries. Thus, each country needs to look for the extent to which psoriasis affects the QoL of its residents. There is a very limited amount of data in the literature about the assessment of the impact of psoriasis on the quality of life of patients living in Saudi Arabia .
Therefore, this study aims to assess the quality of life of adult psoriatic patients attending the outpatient dermatology clinics at King Fahd Hospital of the University in Al-Khobar, Saudi Araba. It is hoped that the results will help in understanding patients' quality of life in Saudi Arabia and aid in the long-term improvement of patients' quality of life and their management in a nationwide scale.

Methods:-
The study was a cross-sectional questionnaire-based study. The validated Arabic version of Dermatology Life Quality Index (DLQI) instrument was used to assess the quality of life. An electronic copy of the questionnaire was distributed to every psoriatic patient who visited the dermatology department, King Fahd Hospital of the University in Al-Khobar from September 2016 to March 2017 through WhatsApp messages. Only patients of 16 years old or above were included in the study. The patients who were unable to speak or understand Arabic were excluded from it.
The DLQI is an instrument that is used to measure the QoL across all skin diseases. (Finlay and Khan, 1994) It has been validated, and used in both high-and low-income countries. (Basra et al., 2008) It is simple and brief, consisting of ten questions, each with four possible answers scored from 0 to 3, covering the last seven days of the patient's life. The DLQI is calculated as the sum of these scores, up to a maximum possible value of 30. The higher the total score is, the greater the impact of the disease. (Finlay and Khan, 1994) The content of the DLQI include all important and key concepts relevant to psoriasis-related symptoms and the impact of these symptoms on patients. In addition to the DLQI instrument, questions about age, gender, nationality, marital status, disease duration, age of onset, smoking, affected areas (e.g. scalp, nails, and joints), and comorbid conditions including depression were added to the electronic questionnaire.
All the participants were informed about the content and the aim of the study. Their participations were anonymous and voluntary.
The data was coded and entered into the SPSS software version 24. All quantitative variables were expressed as a mean ± standard deviation. The relationships between quality of life and the possible related factors were examined using t-test. A P-value of less than 0.05 was considered to be statistically significant.

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A free license has been granted to us to use the DLQI for the purposes of the study, and the ethical approval was obtained from the institutional review board at Imam Abdulrahman bin Faisal University (IAU). The authors have no conflicts of interest that are directly relevant to the content of this study.

Results:-
The number of patients who met the inclusion and exclusion criteria for the specific duration was 208. 36 patients did not have a WhatsApp contact number. 86 adult patients accepted to participate in the study and completed the questionnaire. 2 patients were excluded from the analysis because of not answering two or more questions in the DLQI. The remaining 84 patients were included in the analysis with a final response rate of 40.38%.
The mean age of patients was 37.0 years (SD=12.78). Their age range is between 17 and 73 years. The mean age of psoriasis onset was 22.62 years (SD=11.98). The disease duration ranged from 1 to 45 years (mean, 14.95 ± 11.48 years). 44 (52.38%) patients were female and 40 (47.62%) were males (male to female sex ratio 1:1.1). 78 (92.86%) patients were Saudis, and 6 (7.14%) were non-Saudi. Table 1 shows the details of the clinical and sociodemographic characteristics with relationship of each characteristic to DLQI scores. No significant relationship was identified. The overall average DLQI score was 7.39 out of 30 (SD=5.74) with a range from 0 to 26. As figure 1 shows, psoriasis impaired the quality of life in 74 (88.1%) patients:17 (20.2%) patients were "very largely" (scored between 11 and 20) or "extremely largely" (scored between 21 and 30) affected by the disease. The effect was moderate (DLQI scores of 6-10) in 32 (38.1%) of patients and small (DLQI scores of 2-5) in 25 (29.8%). And, psoriasis has no effect at all in 10 (11.9%) patients (Fig.1). Symptoms & feeling and daily activities were the areas with most QoL deterioration. The aspect of life least affected by psoriasis was leisure. The detailed results of DLQI are shown in table 2.
Groin involvement was the single statistically significant factor that correlates with QoL. The patients with groin involvement (27.38% of patients) had a larger impairment of quality of life than the patients with no groin involvement. The mean DLQI score with groin involvement is 9.87 compared to 6.37 in the others (p-value <0.05). It appears that the quality of life differs in symptoms & feelings, daily activities and treatment parameters.     The current study had some limitations. Firstly, the study was carried out in a single center which only covers a proportion of the vast area of Saudi Arabia. Secondly, all participants were managed in a tertiary hospital with no involvement of other levels of healthcare like primary healthcare centers. In addition, the hospital is operated by a university which possibly makes it different form the governmental hospitals that are run by the Saudi ministry of health and the hospitals in the private sector. Lastly, the sample size was relatively small, and the response rate was lower than what we aimed to.
The DLQI is a simple tool that is very useful in assessing the QoL of psoriatic patients and their response to treatment. (Mazzotti et al., 2003;Lebwohl et al., 2009) Its use in routine clinical settings should be encouraged. A study of 64 consultations where the DLQI was used found that 37 (57.8%) of these consultations influenced the clinicians' treatment decisions. (Salek et al., 2007) It is advisable that every clinician should know that a DLQI score of more than 10 correlates with severe psoriasis, and that a change of DLQI scores between visits of 4 or more is significant. (Finlay, 2005, Hongbo et all, 2005

Conclusion:-
The overall score of DLQI in psoriatic patients living in Saudi Arabia remains high though it might be lower than assumed. The factors that are associated with QoL impairment in Saudi Arabia may differ from those in the other parts of the world. Patients with groin involvement, for example, might have a higher impairment of QoL.