Th e impact of psoriasis on the lifequality : a cohort of 140 Moroccan patients

we used the 16-Skindex as a questionnary for the evaluation of the impact of psoriasis on the life quality of psoriatic patients which include several items: pruritus, psychological impact: “No improving and recidivism, fear of worsening or persisting lesions or scars, frustration, shame, depression and anger “, relationships with others and the integrity in society, Emotional life, impact on daily activities and hobbies.


INTRODUCTION
The Psoriasis is an inflammatory, systemic and multifactorial skin disease affecting about 2% of the Moroccan population [1].It is considered as an autoimmune disease with abnormality of mitosis and differentiation of keratinocytes where the cyclic nucleotide and lipid mediators play a key role [2,3].This systemic disease is also known linked to a great number of comorbidities especially metabolic [4] and psychiatric [5] ones.
The alteration of the life quality of psoriatic patients has been shown in many epidemiological studies in adults and in children [6][7][8][9][10][11][12][13][14].So the aim of our study was to evaluate this psycho-social impact of psoriasis in Moroccan psoriatic patients.life quality if the Skindexis between 10 and 50,and a significant impact on the life quality if the Skindex> 50.
Data analysis was performed using the SPSS 20 software, 2 kinds of analysis were carried out: Descriptive and univariate analysis.
In the univariate analysis: we analyzed the epidemiological and clinical data significantly related to each item of the Skindex.

RESULTS
We collected 140 patients with psoriasis for this study, the mean age was 30.5 years.
58.9 % of our patients were young (between 15 years and 45 years old) and we had a slight male predominance (51 %).Our patients had a moderate socioeconomic level in 55.5 % of cases and 50,4 % of them had a recent psoriasis.
Plaque psoriasis was the most frequent form (80,5%) and we had a scalp involvement in 74.1 % of cases.51,8% of patients had a mild psoriasis while 31.4% had a severe one.
Besides, severe itching was present in 31,9% of our patients and 26,8% of patients had moderate pruritus.Furthermore, 50% of our patients had an important impact on the life quality, 35 % had a moderate impact and 15 % of patients had a low impact on the life quality.

In the Univariate Analysis
The characteristics of psoriasis significantly related to the Pruritus in our population study were: the low SEL (p= 0,05), the Mild psoriasis (p=0,011) and the living in rural areas (p=0,05) while the No improving and recidivism was significantly associated with Young age (p=0,000), Female gender (p=0,000), Psoriatic arthritis (p= 0,004) and Psoriasis of the scalp,the nails and mucosal psoriasis (p=0,000).The Fear of worsening or persisting lesions or scars was more frequent in women (p=0,05) and the Shame was significantly related to the Young age (p=0,02) and Severe psoriasis (p=0,006).Anger was significantly related to severe psoriasis (p=0,013), old one (0,07) and the use of systemic treatments (p=0,046).
However, the following items were not significantly affected or related to a particular characteristics of psoriasis: the frustration, the emotional life, the desire to be accompanied, the impact on daily activities, the sleep quality and Hobbies (Table .II).

DISCUSSION
Psoriasis is a complex multifactorial skin disease which is known linked to manymetabolic [15], autoimmune and psychiatric [10] comorbiditiesthat must be taken into account in the management of this disease [16].
The psychological impact of psoriasis and the alteration of the life quality iscurrently proven in many studies,There are even some series that have proven that this negative impact is stronger than other chronic dermatitis such as atopic dermatitis [17], and that this impact of psoriasis is similar to other dangerous diseases such as breast cancer and certain serious heart diseases [18].Other studies proposed a theory that this alteration of the life quality is compounded by the other comorbidities of psoriasis.Furthermore, a recent study proved that this alteration of the quality of life affects not only psoriatic patients but also their families [19].
In our study, we aimed to evaluate this alteration of the life quality in Moroccan patients, we didn't study the life quality on psoriatic patients families, or the relationship of this impact and comorbidities.So we noticed that the Severity and theduration of psoriasis are the two characteristics significantly related to the general alteration of the life quality which is almost the same for other studies (resumed in Table III).
This impact is also increased by the scalp and nailsinvolvement which affects the general health, emotional life, and increase the severity of psoriasis [20][21][22].In our psoriatic patients,the scalp and nail involvement were significantly related to the fear of recurrence and persistence of lesions which may be explained by the fact that these areas of the body are the symbol of beauty especially in women.
Besides, there is currently a great interest in the psoriatic arthritis (PSA) and his negative impact on the life quality,especially if it complicates skin psoriasis, So several scales for assessing the quality of life of these patients were validated [23,24].
Furthermore, many studies proved the alteration of the life quality in patients with PSA than patients with cutaneous psoriasis only [25,26], except one study which noticed that there was no change in the impairment of the quality of life with the presence of PSA in patients with cutaneous psoriasis using the PSAQOL questionnary [27].In our study, we had a small sample of PSA with skin psoriasis (5 patients) because these patients are also followed by Rheumatologists especially those without skin psoriasis.Despite this fact, we proved that it affected significantly the life quality of our patients especially the fear of no improving and recidivism.

Pruritus
Psoriasis is known among the most pruritic inflammatory dermatoses according to the results of several studies [37][38][39][40][41]. Furthermore, this pruritus increases the negative impact of psoriasis on the life quality such as sleep disorders, sexual, appetite and concentration troubles and the alteration of the quality of work [42][43][44].
In our study,Pruritus was present in 58,7% of our patients and was intense in 31,9%.It was significantly related to the Lower SEL, the origin from rural regions of and it increases the severity of psoriasis.

Depression
If psychiatric comorbidity is important in psoriasis, depression is by far the most common psychiatric illness encountered [45][46][47].The links between psoriasis and depression are not only psychopathological, biological factors may explain this association (elevated levels of substance P and TNF, decreased serotonin levels) [48].
There is thus a vicious circle "psoriasis-alteration of the life quality-depression" which may further complicate the management of psoriasis, because the treatment of psoriasis doesn't improve necessarily the depression.
On the contrary, it is obvious that depressed psoriatic patient could not treat correctly his psoriasis [49].
A UK population-based cohort study of 146,042 patients [50] demonstrated an increased incidence of diagnoses of depression, anxiety and suicidality in psoriasis; the authors estimated that over 10400 diagnoses of depression, 7100 diagnoses of anxiety, and 350 diagnoses of suicidality were attributable to psoriasis each year, while Gupta [51] found that 5.5% of patients with psoriasis had active suicidal ideation and that 9.5% expressed a death wish and that this depression is increased by the pruritus.Another study demonstrated an increased use of antidepressant drugs in psoriasis [52].
In our study, Depression was significantly observed in patients with severe psoriasis and fortunately we had no cases of suicidality.

Sleep Quality
the sleep quality is among the domains the most affected in patients with psoriasis and this Sleep disturbances can cause significant quality of life impairment,which

Method of measurement Results
Taiwanese [28]  2011 480 Dermatology life quality index (DLQI) The psoriasis severity and the young age have a negative impact on quality of life Chilean [29]  2011 153 Skindex 29 Important impact in males , young age , recent psoriasis, facial involvement Japanese [30]  2012 213 Questionnary (total work and productivity impairment) The severity of psoriasis has an impact on work and productivity American [31]  2012 5604 The severity of psoriasis increases the feeling of anger, frustration, embarrassment, pruritus and pain Spanish (Pso life study) [5]   2013 304 Dermatology life quality index (DLQI) Impact parallel to the severity of psoriasis and the involvement of uncovered areas Polish [32]  2013 100 Satisfaction with life scale The importance of satisfaction level increases with age Polish [33]  2013 168 Skindex 29 Important Impact parallel to the severity of psoriasis, young age, somatic symptoms and disease acceptance Iranian [34]  2014 55 Questionnary (social functioning (SF)-36) alteration of the well-being and the quality of work Spanish (Arizona study) [35]   2014 1022 DLQI, Short form 36 questionnary Alteration of quality of life in females with sleep disorders, depression, anxiety Malaysian [36]  2013 was proved in many studies (koo and al [53]; Delfino and al [54]; Hu and al [55].This sleep impairment in psoriasis is known linked to many reasons such as the pruritus, the psychological burden and the obstructive sleep apnea which is a common and an increasingly prevalent sleep disorder that is receiving attention in terms of a potential association with psoriasis, psoriatic arthritis and rheumatoid arthritis [56].
In our study, this sleep quality was not significantly affected,maybe because of spiritual and religious reasons and the role of the family support in our society.

Relationships and Social Integrity
Human kind is known very sociable, but this sociability could be injured in some situations that makes the person want to be alone and distant from others.This situation could be in some chronic diseases like psoriasis.In the same time, psoriasis may attract attention and cause avoidance and public rejection which may cause a disturbance in the social integrity in psoriatic patients.
This social integrity disturbance is proven in some epidemiological studies [57,58] like the survey of Poot [59] that found severe family dysfunction in these patients in comparison with families without a psoriasis.Even in our study, we noticed an alteration of relationships with others especially in young female patients and patients with severe psoriasis with a significant persistence of the desire to be accompanied.
The psoriasis affects also sexual functioning.In Gupta's cross -sectional survey [60] of 120 inpatients, 40% reported a decline in sexual activity since the onset of psoriasis.Another survey of Sampogna and al [61] proved this sexual dysfunctioning.
In our study the sexual life has not been well exploited but psoriasis did not influence significantly the emotional life of our patients.

Anger
Anger is also among the most psychological troubles that we can observe in chronic diseases, unfortunately, it's association with psoriasis has not been well described.
In anIndian recent study [62] of 48 psoriatic patients,the prevalence of anger was estimated: 58.3%, and in another American study, the prevalence of anger was more important: 89% [63].
In our study, we had a low prevalence of anger in comparison with others which may be explained by the religious convictions of our patients.
However, anger was significantly related to severe and old psoriasis and the use of systemic treatments in our patients.
Othersitems: like the fear of no improving and recidivism; the fear of worsening or persisting lesions or scars and the shame were items proved related to psoriasis in our population but were not described in other publications according to our knowledge.
Besides, the frustration and the desir to be accompanied were not related to psoriasis in our population and it were not described enough in the literature since there is just one descriptive American study of 75000 patients that reported the frustration in 89% of psoriatic patients [63].

CONCLUSION
In our study, Severe and old psoriasis causes an important impact on the life quality especially in young females which leads us to insist on the psychiatric approach of these patients to complete the global management of this chronic disease by the realization of a team work containing a psychologist in the special consultation of psoriasis patients.

Statement of Human and Animal Rights
All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008.

Statement of Informed Consent
Informed consent was obtained from all patients for being included in the study.

Table 3 :
Review of literature