|Year : 2018 | Volume
| Issue : 3 | Page : 165-169
Correlation between disease severity, family income, and quality of life in psoriasis: A study from South India
Preethi B Nayak, Banavasi Shanmukha Girisha, Tonita M Noronha
Department of Dermatology, Venereology and Leprosy, K. S Hegde Medical Academy, NITTE (Deemed to be University), Mangalore, Karnataka, India
|Date of Web Publication||2-May-2018|
Banavasi Shanmukha Girisha
Department of Dermatology, K. S Hegde Medical Academy, NITTE (Deemed to be University), Deralakatte, Mangalore - 575 018, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Psoriasis is a common, chronic inflammatory disorder of skin characterized by a long clinical course with exacerbations, remissions, and relapses. The cost of therapy and psychological burden of the disease depends on disease severity. The objective of this study was to assess the quality of life and financial status and to correlate the financial burden of the disease with the severity of psoriasis and quality of life. Materials and Methods: A total of 102 psoriasis patients attending the dermatology outpatient department in our hospital were enrolled in this study. A detailed history and complete physical examination, including, Psoriasis Area and Severity Index (PASI), was done. Their family income was calculated. Quality of life was measured using the dermatology life quality index (DLQI) proposed by Finlay et al. Multiple linear regression was done to identify the predictor variables of quality of life (DLQI). P < 0.05 was considered statistically significant. Results: Among the 102 psoriasis patients 78 were men(76.5%) and 24 were women(23.5%). The mean PASI score was 8.20 ± 6.18 the mean DLQI was 13.01 ± 6.95, and mean family income was INR 15570.10 ± INR 10081.82 per month. There was a significant positive correlation between disease severity and DLQI, and a significant negative correlation between family income and PASI as well as DLQI. Conclusion: The quality of life in psoriasis is affected by both the disease severity and financial status of the patient. The chronic course of psoriasis along with disease severity, in a background of low financial status, impairs the quality of life.
Keywords: Dermatology life quality index, family income, Psoriasis Area and Severity Index, psoriasis, quality of life
|How to cite this article:|
Nayak PB, Girisha BS, Noronha TM. Correlation between disease severity, family income, and quality of life in psoriasis: A study from South India. Indian Dermatol Online J 2018;9:165-9
|How to cite this URL:|
Nayak PB, Girisha BS, Noronha TM. Correlation between disease severity, family income, and quality of life in psoriasis: A study from South India. Indian Dermatol Online J [serial online] 2018 [cited 2019 May 19];9:165-9. Available from: http://www.idoj.in/text.asp?2018/9/3/165/231720
| Introduction|| |
Psoriasis is a chronic, systemic disease with a multifactorial etiology that affects 1–3% of the global population. It is not just one disease, it is turning out to be a syndrome having significant comorbidities. Although psoriasis can present at any age, onset before the age of 30 is more common, such that most patients are affected at the most productive stage of their lives. Psoriasis results in a high cost for the society and the patient, which includes expenses for clinical examination, laboratory examination, treatment, as well as the loss of career productivity. Impact of skin diseases plays a major role in deciding treatment modality. Psoriasis as a disease not only affects an individual but also has an economic burden on their family. Hence, this study was structured to evaluate the effect of psoriasis on an individual physically, mentally, emotionally, and economically. The aim of this study was to assess the quality of life (QoL) and financial status, and to correlate the financial burden of the disease with severity of psoriasis and QoL.
| Materials and Methods|| |
This was a hospital-based study conducted in the outpatient department of Dermatology, Venerology and Leprosy of Justice KS Hegde Hospital attached to KS Hegde Medical Academy, Mangalore from October 2015 to March 2017. One hundred and two patients with a clinical diagnosis of psoriasis were enrolled. After fulfilling the selection criteria, all patients were counseled about the study and informed written consent was obtained. Ethical clearance for conducting this study was obtained from the institutional ethical committee. Inclusion criteria comprised of age >18 years and patients with a diagnosis of psoriasis. A detailed history was taken and complete physical examination was done for all participants.
Physician-rendered clinical measure such as Psoriasis Area and Severity Index (PASI), patient reported outcomes such as dermatology life quality index (DLQI), and monthly family income were used in this study. The most widely used tool for clinical evaluation of patients and for QoL measurement is PASI and DLQI, respectively. PASI was calculated by scoring the lesion for erythema, induration, and desquamation. It also considered the area of the body affected by psoriasis. The severity of PASI score was graded as mild, moderate, and severe with scores of <5, 5–10, and >10, respectively. The questionnaire proposed by Finlay et al. was used to assess DLQI. Higher score of DLQI indicates greater impairment of QoL., The questionnaire was made patient friendly by translating it into local languages. Modified Kuppuswamy's socioeconomic scale, which uses monthly family income to assess financial status, was used in our study. Family income was calculated by adding the monthly income of all the earning members of the family for a month. The questions on demographic data, family income, and DLQI assessment were included in the self-administered questionnaire filled by the patients.
The data collected were entered into Microsoft excel spreadsheet and analyzed using IBM SPSS Statistics, version 22 (Armonk, NY: IBM Corp). Descriptive data were presented in the form of frequency, percentage for categorical variables, and as mean, median, standard deviation, and quartiles for continuous variables. Comparison of the PASI, DLQI, and income was performed using Mann–Whitney U-test. Spearman's correlation test was used to test the correlation between the study variables. Multiple linear regression was done to identify the predictor variables of DLQI. P value of <0.05 was considered statistically significant.
| Results|| |
One-hundred and two patients with psoriasis were included in the study. Majority (76.5%, n = 78) of the psoriasis patients were males, with a male-to-female ratio of 3:1. The patient's age ranged between 18 and 65 years with 38.2% of the patients aged more than 51 years. The mean age was 44 ± 12.31 years. The duration of psoriasis in our patients were ≤1 year in 17 (16.7%), 1–5 years in 61 (59.8%), and ≥5 years in 24 (23.5%). The mean duration of the disease was 5.16 ± 6.42 years. Almost a quarter (23.5%) of the patients had been suffering from the disease for more than 5 years. The most common type of psoriasis was chronic plaque psoriasis (85.3%) followed by localized scalp psoriasis (11.8%). Inverse psoriasis (1%), pustular psoriasis (1%), and erythroderma secondary to psoriasis (1%) were also seen.
The mean PASI score was 8.20 ± 6.18. The mean DLQI was 13.01 ± 6.95, and the mean family income was INR 15570.10 ± INR 10081.82 per month. Thirty-nine patients (38.2%) had a family income between INR 9788 and INR 19574 per month.
In our study, 26 (25.5%) patients were unemployed, out of which 10 (9.80%) were retired and 3 (2.94%) were students. All the 26 patients were dependent on their family income. In our study group, majority (47.1%) belonged to upper middle class according to the modified Kuppuswamy's socioeconomic scale. The sociodemographic profile of the patients is presented in [Table 1]. The difference in DLQI in both the sexes is shown in [Figure 1].
To determine which factors of psoriasis are linked with change in QoL, correlation between QoL and disease severity as well as patients' family income was calculated. The disease severity assessed using PASI score correlated significantly with DLQI (r = 0.815, P = 0.001); higher the PASI score greater the DLQI, and hence, greater is the impairment of QoL [Figure 2]. Family income was also found to have significant negative correlation with DLQI (r = −0.375, P = 0.001), with lower income group having higher DLQI and greater impairment of QoL [Figure 3]. There was also significant negative correlation between disease severity (PASI) and family income (r = −0.323, P = 0.001). Patients with lower monthly income had higher disease severity. The relationship between these three variables are given in [Table 2].
|Figure 2: The graph shows a positive correlation between DLQI and PASI. Higher the PASI greater the DLQI|
Click here to view
|Figure 3: The graph shows a negative correlation between family income and DLQI|
Click here to view
|Table 2: Correlation matrix showing the relationships between age, income, PASI, and DLQI by Pearson's correlation (r)|
Click here to view
These findings led us to hypothesize that QoL in the study population was affected by psoriasis. Hence, we evaluated the combined influence of various variables on QoL by multiple linear regression analysis [Table 3]. Five variables were considered. PASI and monthly family income were significant predictors of DLQI. Higher the severity, greater the impairment of QoL (beta coefficient = 0.72; P < 0.001). Lower the income, greater the impairment of QoL (beta coefficient = −0.15; P < 0.02).
|Table 3: Association of DLQI with clinicosocial factors (multiple linear regression)|
Click here to view
| Discussion|| |
Psoriasis affects patient's life massively, with effects on physical, psychological, and social wellbeing. It is associated with stigmatization and psychological distress; approximately 50% of the patients feel unattractive and anxious because of the disease.,
Psychological stress is also a well-known trigger in psoriasis. It forms the cause or a maintaining factor in the expression of the disease in psoriasis patients. According to a study by Farber et al., 40% of the patients reported psoriasis at the time of worry and approximately 37% had worsening of disease associated with worrying., Approximately 80% of the psoriasis patients complained of stress-related flare of the disease and stress-induced relapse was reported in 90% of the children., There is increased occurrence of depression and anxiety in moderate-to-severe psoriasis patient compared with the general population. There is decreased patient compliance and treatment efficacy in patients with comorbid psychological stress. QoL measurement gives an insight about the psychological status of an individual.
DLQI is a reliable and valid instrument to measure QoL, and is most widely used to assess QoL in psoriasis clinical trials., As psoriasis is a chronic disease with periods of exacerbation and remission, DLQI can act as a reference score, which can be useful in determining the change in QoL before, during, and after treatment due to significant psychological and physical risk in psoriasis.,
This study showed that psoriasis affects DLQI and that the impairment of QoL is directly proportional to the severity of psoriasis measured by PASI. The lowering in DLQI following decrease in PASI denotes the psychosocial wellbeing of the patient following remission or treatment.
Various studies have shown that there was significant worsening of health-related QoL in psoriasis patients compared to healthy controls. A study by Ghajarzadeh et al. studied 100 patients and reported a mean DLQI score of 12.4. Hariram et al. studied 69 patients and reported a mean DLQI score of 11.1. In our study, the mean DLQI score was 13.01, which was similar to that seen in previous studies.
It has been known that psoriasis can influence a patient's life in a cumulative manner which can cause a low income, decrease in survival, and impairment in QoL. Income is the means of fulfilling one's substantial needs. An individual's well-being is dependent on demographic, social, and psychological factors along with a sound income to take care of oneself and one's family.,,, There were increased number of men compared to women in our study (M:F = 3:1). This may be due to higher medical access to men compared to women in this part of the world. As males are the main bread earner of the family in this part of the world, psoriasis can lead to loss of productivity and severely affect the finances of the family. According to our study, using multiple linear regression, we found that QoL had a significant negative association with family income. QoL also had a significant association with disease severity. Psoriasis and the cost of treatment affect an individual, both physically and psychologically. Severity of psoriasis has a negative impact on QoL and family income. It may also lead to higher cigarette smoking and alcohol consumption which adds to the economic burden. Psoriasis can also be aggravated by the stress associated with low financial status as well leading to a self-enhancing vicious cycle.
It must be underlined that our study had several limitations. The study sample cannot be considered representative of general population because it is a single hospital-based study. Our study design also lacks a control group; it is unknown whether healthy individuals of similar age have better QOL, and hence, comparison of these cases with healthy individuals is not possible.
QoL reflects the social, physical, emotional, and psychological status of the patient. In psoriasis patients, it is affected by the severity of the disease and their financial status. As psoriasis is a chronic disease with a fluctuating course, for effective treatment, QoL, loss of productivity, disease severity, and the interplay between them plays a major role. The observations in this study provide an insight on these factors, which has a significant impact on the life of psoriasis patient. Hence, it is advisable to consider the economic status of the patient while choosing the therapeutic option for psoriasis management.
We sincerely thank Dr. Andrew Finlay for granting us permission to use DLQI questionnaire. We also thank Dr Vinayak kamath B for helping us in statistical analysis.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Grover C. Psoriasis. In: Sacchidanand S, editor. IADVL Textbook of Dermatology. 4th
ed. Vol 1. Mumbai: Bhalani Publishing House; 2015.pp1014-89.
Al-Mutairi N, EL Eassa B, Nair V. Measurement of vitamin D and cathelicidin (LL-37) levels in patients of psoriasis with co-morbidities. Indian J Dermatol Venereol Leprol 2013;79:492-6.
] [Full text]
Schons KRR, Beber AAC, Beck MO, Monticielo OA. Nail involvement in adult patients with plaque-type psoriasis: Prevalence and clinical features. An Bras Dermatol 2015;90:314-9.
Hawro T, Zalewska A, Hawro M, Kaszuba A, Królikowska M, Maurer M. Impact of psoriasis severity on family income and quality of life. J Eur Acad Dermatol Venereol 2015;29:438-43.
Mazzotti E, Barbaranelli C, Picardi A, Abeni D, Pasquini P. Psychometric properties of the Dermatology Life Quality Index (DLQI) in 900 Italian patients with psoriasis. Acta DermVenereol 2005;85:40-13.
Mattei PL, Corey KC, Kimball AB. Psoriasis Area Severity Index (PASI) and the Dermatology Life Quality Index (DLQI): The correlation between disease severity and psychological burden in patients treated with biological therapies. J Eur Acad Dermatol Venereol 2014;28:333-7.
Finlay AY, Khan G. Dermatology Life Quality Index (DLQI)]212;a simple practical measure for routine clinical use. Clin Exp Dermatol 1994;19:210-6.
Ghajarzadeh M, Kheirkhah S, Ghiasi M, Hoseini N. Depression and quality of life in psoriasis and psoriatic arthritis patients. Iranian J Dermatol 2012;14.
Park K. Medicine and social health. In: Park K, editor. Park's Textbook of Preventive and Social Medicine. 24th
ed. India: Bhanot Publishers; 2017.pp726-27.
Aghaei S, Moradi A, Ardekani GS. Impact of psoriasis on quality of life in Iran. Indian J Dermatol Venereol Leprol 2009;75:220.
] [Full text]
Van de Kerkhof PCM, Nestle FO. Psoriasis. In: Bolognia JL, editor. Dermatology. 3rd
ed. Spain: Elsevier Ltd; 2012.pp135-57.
Grozdev I, Korman NJ. Psoriasis: Epidemiology, Potential Triggers, Disease Course. In: Weinberg J M, Lebwohl M, editors. Advances in Psoriasis. 1st
ed. London: Springer-Verlag; 2014.pp27-7.
Burden AD, Kirby B. Psoriasis and related disorder. In: Graffiths CEM, Barker J, Bleiker T Chalmers R, Creamer D, editors. Rook's Textbook of Dermatology. 9th
ed. Vol 1. Chichister: John Wiley & Sons, Ltd; 2016.pp35.1-35.48
Nyfors A, Lemholt K. Psoriasis in children: A short review and a survey of 245 cases. Br J Dermatol 1975;92:437-42.
Badia X, Mascaro J M, Lozano R. Measuring health-related quality of life in patients with mild to moderate eczema and psoriasis: Clinical validity, reliability and sensitivity to change of the DLQI. Br J Dermatol 1999;141:698-702.
Sampogna F, Tabolli S, Söderfeldt B, Axtelius B, Aparo U, Abeni D, et al
. Measuring quality of life of patients with different clinical types of psoriasis using the SF-36. Br J Dermatol 2006;154:844-9.
Hariram P, Mosam A, Aboobaker J, Esterhuizen T. Quality of life in psoriasis patients in KwaZulu Natal, South Africa. Indian J Dermatol Venereol Leprol 2011;77:333-4
Diener E, Seligman MEP. Beyond money toward an economy of wellbeing. Psychol Sci Public Interest 2004;5:1-31.
Kenny C. Does development make you happy? Subjective wellbeing and economic growth in developing countries. Soc Indic Res 2005; 73: 199-219.
Li-Ping, Tang T. Income and quality of life: Does the love of money make a difference? J Bus Ethics 2007;72:375-93.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]