الفهرس 
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Abstract
Psoriasis is a chronic, immune mediated inflammatory skin disease, consisting of red, scaly plaques occurring most commonly on the elbows, knees, scalp, and lower back, but any skin surface can be involved (Griffiths and Barker, 2007).
The prevalence of psoriasis in adults range between 0.27% and 11.4% (Li et al., 2012; Parisi et al., 2013). Higher prevalence rates have been reported at higher latitudes and in white people compared with other ethnic groups (Farber and Nall, 1998).
Psoriasis is considered a systemic disease; it is associated with psychological, metabolic, arthritic and cardiovascular comorbidities. Lifespan is reduced as a consequence. In addition to the psychological and social burden related to psoriasis, the cost to patients and healthcare systems is high (Springate et al., 2017).
A cross sectional study, was conducted on 200 patients with psoriasis aged from 6 up to 78 years old of both sexes to detect the demographic, clinical and laboratory characteristics of psoriasis patients.
In current study, the mean age of the studied sample was 42.83 ± 17.3 years and the mean age at onset of psoriasis was 35.82 ± 17.9 years. Male predominance was found in 60% of psoriasis patients. Psoriasis was more common in rural than in urban areas (53% versus 47% respectively). As regard educational level; 44% of psoriasis patients were illiterate, 32% secondary educated (high school) and 14.5% highly educated (college). The prevalence of psoriasis in working people was 53%.
Married psoriasis patients represented 73% of the studied sample. Smokers represented 47% of the psoriasis patients and 56.6% of them were heavy smokers. Family history of psoriasis was positive in 66% of patients, 68% of the patients had positive history of consanguinity and the most common detected degree of consanguinity was the 1st degree in 39.7% of the patients.
Psoriasis was of gradual onset in 91% of the cases, progressive course in 75% and the mean duration of psoriasis was 6.99 ± 3.9 months. The most common symptom associated with psoriasis was itching which was reported by 72.5% of psoriasis patients.
Psoriasis vulgaris was the most common type in 69.5% of the patients, erythrodermic psoriasis in 8%, nail psoriasis in 7% and guttate psoriasis in 5.5% of the patients. There was a statistical significant relation between the type of psoriasis and age of the patients as P value < 0.001 in which the mean (± SD) of age in psoriasis vulgaris was 45.8 ± 15.6 years, 47.7 ± 15.8 years in erythrodermic psoriasis, 35.7 ± 5.9 years in nail psoriasis and 16.0 ± 8.2 years in guttate psoriasis.
There was a statistically significant relation between the type of psoriasis and educational level of the patients as P value = 0.004. Psoriasis vulgaris was observed in 82.8% of secondry educated patients and nail psoriasis in 15.8% of the patients with higher educational level. Guttate psoriasis was common in 24.1% of basically educated patients. In this study; there was a statistical significant relation between type of psoriasis and having a job as P value = 0.010. Employee was detected in 70.8% of psoriasis vulgaris and 13.2% in erythrodermic psoriasis.
The most common affected sites with psoriasis were upper limbs in 78% of the patients followed by lower limbs in 77.5% and nail in 65% (11% of them only nail psoriasis and 89% of the patients as apart of psoriatic lesions). Mixed nail changes were found in 58.5% of the patients followed by regular coarse pitting 37%, subungual hyperkeratosis 3% then onycholysis 1.5%. There was a significant relation between the severity of psoriasis and site of affection as P value < 0.001. Psoriasis was severe in 91.2% of the patients with upper limb affection, 89.5% of lower limb, 86.8% of nail and 78.9% in scalp affection. As regard BSA; it was mild in 17% of the patients, moderate in 26% and severe in 57%.
Aggravating factors were detected in 98% of psoriasis patients. Seasonal variation was the most common excacerbating factor of psoriasis and it was detected in 51.5% o f the patients; winter exacerbation was found in 48% of these patients. Stress was detected in 21% of the patients. Medications represented 20.4% of excacerbating factor; where β blockers were the most common aggravating drug in 17% of the patients.
Percentage of psoriasis patients who received therapy was 96.5%. Topical therapy only was used by 36% of the patients. The most common used topical therapy was combination (topical corticosteroids + emollient) in 58%. Phototherapy ”NB: UVB” was combined with topical treatment in 18.5%. Systemic medications combined with topical were used by 42% of the patients. Parentral methotrexate was the most common used systemic medication in 31.1%. Biologic (ustekinumab) was used by 1.6% of the patients.
Psoriatic arthropathy was found in 12.5% of psoriasis patients. Symmetric PSA was detected in 28%, followed by distal interphalangeal predominance and spondylitis in 16% for each then asymmetric in 12% of the patients. PSA was detected in 52% of patients with nail psoriasis.
Oral lesions were detected in 19.5% of psoriasis patients. The most common oral lesion was geographic tongue in 49% of the patients. Oral lesions were observed in 38.5% of erythrodermic psoriasis patients, 33.3% of psoriasis vulgaris and 17.9% of pustular psoriasis. ENT affection was observed in 27.5% of psoriasis patients, 20% of them had pharyngitis (all of them with guttate psoriasis). Otitis externa represented 22% of the patients (40% of psoriasis vulgaris patients, 27.3% of erythrodermic and 12.7% of pustular psoriasis). This relation between ENT affection and types of psoriasis was statistically significant as P value = 0.001.
Ocular affection was observed in 18% of psoriasis patients. Eye lesions were detected in 77.8% of psoriasis vulgaris patients and 16.6% of erythrodermic psoriasis.This relation was statistically significant as P value = 0.049. Conjunctivitis and dryness were the most common ocular manifestations and were detected in 94.4% and 19.4% respectively.
As regard laboratory investigations of psoriasis patients; iron deficiency anemia was detected in 31% of the patients. The mean (± SD) of ESR in 1st hour was 28.50 ± 21.1. There was statistically significant difference between the mean (± SD) of ESR and types of psoriasis as P value = 0.008. In pustular psoriasis was 57.58 ± 42.01, in guttate psoriasis 32.27 ± 31.26, in psoriasis vulgaris 29.98 ± 30.24 and in erythrodermic psoriasis 24.19 ± 19.52. CRP was elevated in 42% of the patients. Insignificantly CRP was elevated in 75% of psoriasis vulgaris patients and of equal percentage in guttate, pustular psoriasis and erythrodermic psoriasis patients of 6% for each. RF was positive in 12.5% of the patients with psoriatic arthritis. Elevated FBG level was detected in 15% of psoriasis patients, hypertriglyceridemia in 45% and low - HDL in 58.5%. HCV infection was detected in 4.5% of psoriasis patients and HBV only in 0.5%.
The mean (± SD) weight of psoriasis patients was 74.93 ± 18.8 kg, BMI was 26.74 ± 5.3 and central obesity was detected in 54.5% of patients. MetS was detected in 36% of psoriasis patients and it was common in males 58.3%. It was significantly more common in patients with severe psoriasis 68.1%. MetS associated with smoking was observed in 50% of psoriasis patients. MetS was more common in psoriasis vulgaris patients 80.6%. This relation between type of psoriasis and MetS was statistically significant as P value = 0.010.
Associated comorbidties with psoriasis were found in 74.5% of the patients. Liver diseases were the most common one in 29.5%, followed by type 2 DM in 19.5% and hypertention in 18.5% of psoriasis patients. Psychological impairment was detected in all psoriasis patients. Stress was detected in 21%.
Pediatric psoriasis was detected in 10.5% of psoriasis patients. The mean age (± SD) of the patients was 12.29 ± 4.26 years. Female represented 71.4% of the pediatric psoriasis patients. Psoriasis vulgaris was the most common type of pediatric psoriasis which was detected in 47.6%, guttate psoriasis in 33.3% and nail psoriasis in 14.2%.
Conclusion
This study describes the sociodemographic, clinical and laboratory characteristics of psoriasis patients in Sohag, Upper Egypt.
In current study we concluded that; psoriasis is a chronic, genetic, multisystemic disease, affects all age groups, more common in males than females and can be affected with residence, educational and occupational level of the patients. Psoriasis may be triggered or exacerbated by seasonal variation, infections, physiological impairment, drugs and smoking.
We concluded that psoriasis vulgaris is the most common type of psoriasis and the most common affected sites with psoriasis were the sites of trauma (upper, lower limbs and nails). Psoriasis was severe in patients with upper limbs, lower limbs, nails and scalp affection. PSA was more common in nail psoriasis than other types of psoriasis. We detected an association between psoriasis and oral lesions such as geographic tongue. Also we observed ENT affection as pharyngitis in psoriasis patients.
We observed ocular affection in psoriasis patients in about 18% of psoriasis patients due to decreased awareness of the relation between psoriasis and ocular affection.There was a significant association between psoriasis and MetS and it was significantly more common in smoker male patients and in severe types of psoriasis. Psychosocial problems were detected in all psoriasis patients. Stress was found in about 1/5 of the patients.
Psoriasis is associated with increased risk for comorbidities including; PSA, MetS (including type 2 DM, HTN and obesity), cardiovascular disease, fatty liver disease, hepatitis). Also we observed anemia, elevated ESR and CRP level in psoriasis patients.
Recommendation:
Further studies with larger sample size, longer duration of follow up, team work with other specialists (Rheumatology, ENT, Ophthalmology, Tropical & Gastroenterology, Internal Medicine, Nutrition, Cardiology, Pediatric and Psychiatry) are necessary for early detection of any abnormality and to improve patient quality of life. Health care providers and patients should be aware of the need to follow up for assessment and early detection of any systemic diseases associated with psoriasis. Patients should know that making simple lifestyle changes, such as stop smoking, weight reduction, regular exercise, stop any drug exacerbating psoriasis and good nutrition in psoriasis patients may be beneficial.
We suggest regular follow up of psoriasis patients especially nail psoriasis at the outpatient rheumatology clinic to detect early joint affection and avoid joint deformities.
We suggest further awareness and routine ocular examination with more ocular investigations for psoriasis patients for detection of major eye problems as (uveitis). All psoriasis patients should be screened for MetS to detect any abnormality especially in psoriasis patients with family history of psoriasis, DM and HTN to prevent significant morbidity and mortality.
We must take psychological status of the patients into account as apart of the management of psoriasis. The recognition of stress and its specific treatment should be considered as an integral part of the treatment of a patient with psoriasis. Improved psychosocial status of the patients may considerably improve the management of psoriasis patients in all age groups.
Routine investigation as CBC is important for detection of anemia and early correction of anemia. ESR and CRP are inexpensive markers determining disease severity and systemic inflammation in psoriasis patients, so should be done. We need serology for HCV and HBV suspected patients as HCV infection is epidemic in Egypt with high prevalence and it affect the management of psoriasis patients.