Indian Dermatology Online Journal

ORIGINAL ARTICLE
Year
: 2018  |  Volume : 9  |  Issue : 6  |  Page : 394--404

Narrow-band UVB phototherapy does not consistently improve quality of life in psoriasis patients: A prospective observational study from Eastern India


Shweta Arora, Bikash R Kar 
 Department of DVL, Institute of Medical Sciences and SUM Hospital, S'O'A University, Bhubaneswar, Odisha, India

Correspondence Address:
Bikash R Kar
Department of DVL, Institute of Medical Sciences and SUM Hospital, S‘O’A University, Bhubaneswar - 751 003, Odisha
India

Abstract

Introduction: Psoriasis is a chronic inflammatory and proliferative condition of the skin which is well-known to impair the patients' quality of life (QoL). Of the various treatment modalities, narrowband UVB (NBUVB) phototherapy is one of the standard treatments for moderate to severe plaque psoriasis with minimal side-effects compared to other systemic therapies. Objectives: To study whether NBUVB phototherapy administration improves QoL in plaque-type psoriasis and to find the correlation between clinical severity of psoriasis and patients' QoL by using psoriasis area severity index (PASI), dermatology life quality index (DLQI), and psoriasis disability index (PDI) tools before and after NBUVB phototherapy. Materials and Methods: Thirty-seven patients with plaque psoriasis involving >10% of body surface area (BSA) underwent NBUVB phototherapy thrice weekly for 36 sessions. Clinical severity of psoriasis was assessed by PASI and impact of psoriasis on quality of life by DLQI and PDI. Assessment was done at the baseline, 18th, and 36th session. Results: After 36 sessions of NBUVB phototherapy, mean reduction in PASI was 79.6% which was statistically significant. On the other hand, DLQI and PDI did not show significant improvement and did not correlate with PASI. Conclusion: NBUVB phototherapy reduces clinical severity of psoriasis. However, clinical severity and QoL impairment is independent of one another. DLQI and PDI do not improve proportionate to clinical improvement.



How to cite this article:
Arora S, Kar BR. Narrow-band UVB phototherapy does not consistently improve quality of life in psoriasis patients: A prospective observational study from Eastern India.Indian Dermatol Online J 2018;9:394-404


How to cite this URL:
Arora S, Kar BR. Narrow-band UVB phototherapy does not consistently improve quality of life in psoriasis patients: A prospective observational study from Eastern India. Indian Dermatol Online J [serial online] 2018 [cited 2019 Jul 17 ];9:394-404
Available from: http://www.idoj.in/text.asp?2018/9/6/394/245013


Full Text



 Introduction



Psoriasis is a chronic inflammatory skin disease affecting 2–3%[1] of the population. The symptoms lead to physical discomfort as well as impairment of patient's quality of life (QoL).[2] However, psychosocial disability produced by psoriasis may not parallel the physical extent of the disease.

Psoriasis area severity index (PASI) is a validated tool for assessing the clinical severity of psoriasis. Generic, skin-specific, disease-specific, or mixed tools can assess quality of life. Dermatology life quality index (DLQI) is a simple, practical, reliable, and valid dermatology-specific QoL instrument.[3] On the other hand, psoriasis disability index (PDI) is a disease-specific health-related QoL instrument developed for psoriasis patients by Finlay in 1993.[4] Both the tools measure QoL over previous four weeks.

The treatment is often challenging because of the huge impact of psoriasis on QoL. In 1976, Fischer[5] found the utility of NBUVB in chronic plaque psoriasis, which is now the first line of treatment for moderate to severe forms.[6]

 Materials and Methods



This was a prospective, observational study carried out in the dermatology department of a tertiary care teaching hospital in eastern India from December 2014 to June 2016 after obtaining approval from the institutional ethical committee. Thirty-seven patients above 16 years of age with plaque-type psoriasis involving >10% of body surface area (BSA) and good understanding of English/Hindi language were included in the study. The patients with pre-existing light aggravated disease/on phototoxic medications, history of previous/existing malignancy, guttate or erythrodermic psoriasis, psoriatic arthritis, and involvement of palms and soles were excluded from the study. The flow of the patients in this study is depicted in [Figure 1].{Figure 1}

Patients on systemic antipsoriatic medications were given a washout period of 4 weeks during which they were prescribed antihistamines and bland emollients. They were subjected to whole-body narrowband UVB (NBUVB) phototherapy thrice weekly for 36 sessions. Starting with 300 mj/sq.cm, a stepwise increment of 20% was done at each sitting based on patient's erythema response. In case of moderate to severe erythema or blistering, phototherapy was stopped until fading of erythema and restarted with 50% of the previous dose without further dose increase.

Twenty-nine patients were analyzed using PASI, DLQI, and PDI at the baseline, 18th, and 36th sessions. In the follow-up visit done after 1 month of stopping treatment, only PASI was calculated. PASI response was graded as excellent, good, and poor when there was 75–100%, 50–75%, and <50% reduction in PASI, respectively.

DLQI questionnaire [Annexure 1] contains 10 questions with a maximum attainable score of 30 and PDI questionnaire [Annexure 2] consists of 15 questions with a maximum attainable score of 45. For both DLQI and PDI, scoring of each question was done as follows: very much = 3, a lot = 2, a little = 1, not at all = 0, and questions not answered = 0.[INLINE:1][INLINE:2]

Grading of DLQI scores was done as follows: score 0–1: no impact on QoL, 2–5: small effect, 6–10: moderate effect, 11–20: large effect, 21–30: extremely large effect.

Statistical analysis

Mean and standard deviation for linear variables such as age, PASI, DLQI, and PDI, and paired t-test was done to show whether improvement in scores was significant. Pearson's correlation analysis was done to find out the association between PASI and QoL. P value of <0.05 was considered statistically significant.

 Results



In total, 37 patients were recruited, out of which 3 patients dropped out because of flare-up during the washout period, 2 patients had phototoxic reaction, and 3 were lost to follow-up. In total, 29 patients with male:female ratio of ~2:1 were analyzed. Mean age at presentation was 40.17 ± 15.53 years. Mean duration of disease was 7.89 ± 6.31 years. The mean age at onset was 32.27 ± 15.51 years. Eleven patients had an associated comorbid condition in the form of diabetes mellitus in 3 patients, mitral stenosis in 2, and hypertension, obesity, dyslipidemia, seizure disorder, hypothyroidism, and glaucoma in 1 patient each. [Table 1] shows the demographic profile of the patients.{Table 1}

According to reduction in PASI score, 22 patients had an excellent response, 5 had a good response, and 2 showed a poor response to NBUVB phototherapy. The mean reduction in PASI score was 79.6%. However, the decline in DLQI and PDI scores were not statistically significant [Table 2].{Table 2}

Overall, there was significant reduction in PASI. Although PASI reduction did not differ according to age at presentation or age at onset, when compared to males, females showed a significant response [Table 3]. At 1-month follow-up, all 27 responders were in remission, i.e., no significant change was noted in PASI scores.{Table 3}

Before starting the therapy, the highest DLQI score was 24 and the lowest was 2. Post-therapy 12 patients were in the similar impact group as before showing no change in DLQI and 12 patients showed improvement, i.e., 2 patients shifted from extremely large effect group to very large effect group, 4 and 1 from very large to moderate and small effect group, respectively, and 5 from moderate to small effect group. However, 5 patients showed deterioration in DLQI scores after NBUVB phototherapy, i.e., 3 patients shifted from moderate to very large effect group and 2 patients shifted from small to very large effect group [Table 4].{Table 4}

Highest PDI score at the time of recruitment was 32 and lowest was 1; post-phototherapy, 31 was the highest and 2 was the lowest PDI score. [Figure 2] represents response to individual questions in PDI questionnaire.{Figure 2}

There was no significant difference in QoL before and after therapy according to age at onset and age at presentation. However, impairment in QoL was statistically significant in females compared to males before initiating therapy as well as after completion of 36 sessions of NBUVB phototherapy only with regards to DLQI but not PDI [Table 5].{Table 5}

There was decline in DLQI and PDI till the 18th sitting of phototherapy after which DLQI score was static and PDI score showed a slight increase at the 36th session despite a regular decline in PASI [Figure 3].{Figure 3}

Pearson coefficient analysis demonstrated significant positive correlation between DLQI and PDI. However, no significant correlation was found between PASI vs. DLQI and PDI before or after NBUVB phototherapy [Table 6].{Table 6}

 Discussion



Starting dose of NBUVB was chosen to be 300 mj/sq.cm as most patients in our setup have Fitzpatrick skin type IV, for whom minimal erythema dose should be 320 mj/sq.cm. Moreover mean minimum erythema dose for NBUVB in Indian patients was estimated to be 300 mj/sq.cm by Serish and Srinivas.[7]

Thrice weekly regimen of NBUVB phototherapy was effective to clear psoriasis in 80% of the patients faster than twice weekly regimen.[8] A total of 15–36 sessions are usually required for significant clinical improvement.[9] Therefore, we opted for thrice weekly regimen for a total of 36 sittings. Early-onset psoriasis comprises 70% of all psoriatics,[10] and we found a similar result with 68.9% of the patients in the early-onset psoriasis group and mean age at presentation was 40.17 ± 15.53 years, which was comparable to other studies.[11],[12],[13]

Psoriasis is known to affect both sexes equally. However, male: female ratio was 2:1 in this study and other studies,[14],[15],[16] possibly because the study population was derived from hospitals and females show reluctance to visit hospital regularly for phototherapy.

The mean duration of disease in our study is 7.89 ± 6.31 years, which is similar to that in Root's study.[17] However, mean duration was 16 ± 1.36 years in the PLUTO study[16] and 4.71 ± 2.96 years[18] in a study from Saudi Arabia. This could be due to the fact that patients shift their places of treatment for newer and promising therapies.

Improvement in PASI in our study (79.6%) is in accordance with Yones et al,[19] and Al-Suwaidan.[20] In a SriLankan study,[11] it was concluded that patients with longer duration of illness show poor response to NBUVB treatment. However, we did not find any significant difference in response between early-onset and late-onset group of patients. Although there was significant PASI reduction in both sexes, it was statistically significant in females. Ryan et al.[21] found female sex to be a positive predictor for clearance. Contrary to this, Yones et al.[19] found that age, sex, and MED do not have a significant effect on clearance rate.

In contrast to our observation, significant reduction in DLQI was seen post NBUVB phototherapy in studies by Al-Robaee et al.[18] and Ryan et al.[21] DLQI impairment before therapy was more in patients below 40 years of age, which can be explained by the fact that people in that age group are more concerned about their appearance and are more likely to be socially interactive. This finding was consistent with the study by Barot et al.[15] and Lin et al.[22] However, after therapy, DLQI was more impaired in patients above 40 years of age, which can be attributed to the vast information about chronic relapsing course of the disease available on social platforms. However, age may not be a strong contributor to the outcome of DLQI and PDI as patients <40 years of age can also have multiple remissions and relapses.

According to age at onset, DLQI was more impaired in patients with early-onset psoriasis both before as well as after therapy possibly because of several relapses experienced by patients over a period of time. Psoriasis had a very large impact on DLQI in females both pre and post-phototherapy, and it has been shown previously that stigmatization in more in women.[23]

Divergent to the observation by Gupta et al.[24] and Schiffner et al.,[25] we did not find statistically significant reduction in PDI scores.

Among the individual sections in PDI, the most affected area was daily activities and the least affected area was personal relationships both before as well as after therapy. Finlay[2] also reported the score to be lowest in personal relationships; however, treatment section scored highest in their study. However, in a study by Gupta et al.,[24] daily activities were limited in 72% of the patients before therapy, 49% complained that their lives were affected even after phototherapy, but 57% were able to restart their activities after completion of phototherapy.

Psoriasis interfered with carrying out work around garden/house (question 1) probably because of the extra time spent for therapy every other day. With NBUVB phototherapy, decrease in the frequency of washing/changing or wearing different types of clothes (questions 2 and 3) and taking baths more often (question 5) can be attributed to visible clinical improvement. Increase in the degree of problem at hairdresser because of psoriasis (question 4) can be due to less improvement in scalp psoriasis with phototherapy.

While on therapy, patients lost time off work/school (question 6a) because they had to visit hospital for phototherapy. However, psoriasis did not prevent them from doing things at work (question 7a) probably because psoriasis did not disable them physically. However, in nonworking patients normal daily activities were not stopped (question 6b) as those patients were either housewives or retired from their job. However, there was an alteration in carrying out normal daily activities (question 7b) as they had to spend time to take care of their disease. Career was affected in only 3 patients (10.3%) (question 8) in our study and none of the patients lost their job, possibly due to the knowledge that disease is neither contagious nor life threatening. Similarly Weiss et al,[26] and Finlay[2] found that career was affected in 22.9% and <30% of patients, respectively. Gupta et al.[24] reported loss of job in 1 patient, and in another study,[13] 6% of the patients were laid off from job because of psoriasis.

Although most of the patients did not report sexual difficulties (question 9), worsening of score in few patients may be due to self-consciousness or low response of perineal lesions secondary to covering of the area during phototherapy. Non-affection of relationships with partner/friends/relatives (question 10) in most of the patients may be due to better understanding about disease, whereas deterioration in few patients may be due to persistence of stigma caused by psoriasis among relatives/friends.

With NBUVB phototherapy, patients were able to attend social functions (question 11); however, worsening of scores in 8 patients (27.6%) may be due to self-inhibition behavior to avoid comments by strangers. Gupta et al.[13] found inhibition in social activities in 28% of the patients. There were no sports difficulties (question 12) in a majority of patients (79.3%) as sports activity participation is not common in this study population. Similar results were noted in a south Indian study.[14] Patients were not criticized or stopped from using community bathing or changing facilities (question 13) either because of awareness about the noncontagious nature of the disease among public or because it is not a common practice in India. In contrast to our finding, Weiss et al.[16] and Gupta et al.[13] reported this problem in 82.9% and 50% of the patients, respectively. Psoriasis resulted in 27.6% of the patients to drink alcohol or smoke more than usual (question 14) probably due to set up of vicious cycle i.e., psoriasis → isolation → depression → alcohol/smoking → aggravation of psoriasis. Similarly, in the study by Finlay[2] <30% of respondents marked either “a lot” or “very much” as a response.

After completion of 36 sessions of phototherapy, psoriasis or treatment for psoriasis made patients' home less messy or untidy (question 15) because of good clinical response and proportionate mood change. Worsening in few patients (10.3%) may be due to relatively poor clinical response.

QoL changes did not differ significantly in patients with age <40 years and >40 years and in early-onset and late-onset psoriasis group. In contrast to our finding, Barot et al.,[15] Lin et al.,[22] and McKenna and Stern[27] reported that impact on QoL is greater in young age. Though PDI did not show significant difference between males and females, DLQI changes were statistically significant in females. Overall, we did not find significant improvement in QoL with NBUVB phototherapy. Our result was consistent with the studies by Augustin et al.,[12] Root et al.,[17] and McKenna and Stern.[27] In contrast, Al-Robaee et al.,[18] Gupta et al.,[24] and Lim and Brown[28] demonstrated significant improvement in QoL with NBUVB phototherapy.

The trend in fall in DLQI and PDI showed no significant change after the 18th session probably secondary to loss of time or wages. Moreover, learning the relapsing nature of the disease and temporary benefit of treatment might also be the reason for no further improvement in QoL.

This study revealed poor correlation between PASI and DLQI and PDI, which was consistent with the study by Raddadi et al.[29] and Fortune et al.[30] On the other hand, some studies found moderate correlation between PASI and PDI,[14],[31] while in others PASI and DLQI did not correlate pre-phototherapy but QoL improvement paralleled PASI score improvement post-phototherapy.[19],[32] The results of different studies have been summarized in [Table 7].{Table 7}

Despite improvement in clinical severity, QoL measures did not show significant improvement. This can be attributed to (i) frequent hospital visits, which can be time consuming, and the hospital environment can make the patient feel more sick; (ii) inadequate counseling regarding the relapsing course of disease; (iii) presence of associated comorbidities; (iv) unnecessary self-learning from the internet; (v) most subscales of DLQI and PDI have a substantial floor effect suggesting that these instruments may have decreased sensitivity to change in mild to severe psoriasis.[33]

Limitations

Small sample sizeShort follow-up period of 1 month after completion of therapyThe impact of psoriasis on emotional aspect of QoL was not estimatedDLQI and PDI were not recorded in the follow-up visitImpact of metabolic syndrome or its components on DLQI and PDI could not be analyzed because of the small sample sizeOnly graduates and above with a good understanding of English and Hindi were included even if they may not be the representative of the entire psoriatic population.

 Conclusion



Though NBUVB phototherapy improves psoriasis, it does not improve QoL significantly. Clinical severity of psoriasis and QoL are independent of one another. Fall in DLQI and PDI is not proportionate to the decline in PASI. Clinical improvement and QoL are independent of age at onset or age at the time of presentation. However, PASI and DLQI improved significantly in females as compared to males.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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