Dermatology: Practical and Conceptual Original Article | Dermatol Pract Concept. 2023;13(3):e2023209 1 Prevalence of Female Sexual Dysfunction Among Psoriatic Females: A Cross Sectional Case Controlled Study Mohamed L. Elsaie1, Noha S. Hanafy1, Sherief M. Hussein1, Ola O. Abou Zeid1, Mohamed S. Zaky2, Ramadan M. Eldahshan2, Hesham A. Nada3, Osama Sayedahmed2, Yasmin B. El Zawahry1 1 Department of Dermatology, Medical Research and Clinical Studies Institute, National Research Centre, Egypt 2 Department of Dermatology, Venereology and Andrology, Damietta Faculty of Medicine, Al-Azhar University, Egypt 3 Department of Dermatology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt Key words: Female sexual dysfunction, Marriage, Psoriasis, Female, Autoimmune Citation: Elsaie ML, Hanafy NS, Hussein SM, et al. Prevalence of Female Sexual Dysfunction among Psoriatic Females: A Cross Sectional Case Controlled Study. Dermatol Pract Concept. 2023;13(3):e2023209. DOI: https://doi.org/10.5826/dpc.1303a209 Accepted: March 23, 2023; Published: July 2023 Copyright: ©2023 Elsaie et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing Interests: None. Authorship: All authors have contributed significantly to this publication. Corresponding Author: Mohamed L. Elsaie, MD, Department of Dermatology, NRC, Egypt. ORCID : 0000-0001-7541-5241 Tel: +201099501169 Email: Egydoc77@yahoo.com Introduction: Sexual relationships are an integral part of females psychological and physiological wellbeing. Objectives: The study aimed to identify prevalence and impact of Female Sexual Dysfunction (FSD) in women affected with psoriasis. Methods: This cross-sectional study was carried out on 150 married females who were interviewed to answer Female Sexual Function Index (FSFI) questionnaire and were divided into two groups: the first group included 100 female patients complaining of psoriasis (50 suffering from moderate psoria- sis and 50 with severe psoriasis). The disease severity was graded according to the Psoriasis Area and Severity Index (PASI) while the second group included 50 age matched women who served as controls. Results: Female sexual dysfunction (FSD) in psoriasis female groups was higher than that in the con- trol group (47%, 24%, P < 0.05). The mean total scores of FSFI ranged from 12.30 to 34.20 and were significantly lower in the severe PASI affected group (22.34 ± 5.35) when compared to moderate PASI group (26.24 ± 2.67) or control group (28.79 ± 2.22). In addition, total scores were significantly lower among moderate PASI affected females when compared to control group. ABSTRACT 2 Original Article | Dermatol Pract Concept. 2023;13(3):e2023209 Introduction Psoriasis is a chronic condition that impacts self-perception of oneself. Psychological evaluation is of extreme impor- tance to identify to what extent psoriasis may influence sexual health and to what extent patients are susceptible to psychiatric disorders [1,2]. Psoriasis and Psoriatic arthritis are multifactorial chronic disorders whose etiopathogenesis essentially derive from the alteration of several signaling circuits that affect the func- tional and structural property of the skin. In fact, the mod- ulation of expression profiles of KRTs in keratinocytes and the consequent alteration of cell‐cell and cell‐matrix interac- tions (in which COLs play a fundamental role) contributes to the hyperproliferation of keratinocytes, enhancement of immuno‐inflammatory responses with over‐production of cytokines by Th1 and Th17 cells, which, ultimately, lead to the dysregulation of epidermis homeostasis [3,4]. Finding of psychiatric morbidity in patients with Psori- asis can be explained by the associated stigma which is fre- quently experienced by patients. Stigmatization in psoriasis and experiencing social rejection and avoidance for fear of infection or filth is common and rather affects and devas- tates patients quality of life (QoL). This leads to social em- barrassment, withdrawal and low social interactions [5]. Studies have compared the effects of psoriasis on QoL to that of major diseases like cancer and depression. Self-perception and self-acceptance as a desirable human being are significantly distorted among psoriatic patients which negatively impacts all aspects of life [6,7]. Egyptian community is conservative in nature and the topic of sexuality in general remains to be a taboo in many communities and data related to sexual health and dysfunc- tion or its prevalence remains to be under reported. Previous studies reported sexual dysfunction to range between 52.8% and 76.9% among Egyptian females [8-10]. Objectives The scarcity and rarity of studies identifying the impact of psoriasis on sexual health of Egyptian females led us to per- form this cross-sectional observational study to evaluate the frequency and associated factors of FSD in Egyptian women suffering from psoriasis. Methods This cross-sectional study was approved by the ethical com- mittee and study review board. After consideration, one hundred and fifty married women were recruited into two groups to answer Female Sexual Function Index (FSFI) ques- tionnaire over a period from January 2022 to October 2022. Group 1 included 100 females diagnosed with psoriasis at- tending for consultation or regular follow ups at the outpa- tient clinic and the second control group (group 2) included 50 women not suffering from psoriasis; recruited from hos- pital staff or attendants with patients at different hospital clinics and who served as controls. Recruited females for the study were instructed and explained the study procedures and signed an informed consent before starting of the study. Subjects were eligible for inclusion if were females, were 18-40 years old, were married for at least 1 year, and have had a stable marital relationship. As for the psoriatic group, female patients aged 18-40 and with moderate-to-severe plaque psoriasis vulgaris defined as body surface area (BSA) affected ≥ 10% were included. Those with records of mastec- tomy, oophorectomy, pregnancy or suffering from any gyne- cological disorders or on an ongoing course of psychotropic medications were excluded. Moreover, those giving history of a sexual disorder among their spouses were excluded. Study Procedures All participants underwent the following: 1. History Taking Patients data including age, body mass index (BMI), educational level, onset, course and duration of psoriasis, past history of any medications used and durations of use were all identified. Moreover, family history of psoriasis and associated comorbidities (metabolic syndrome, hy- pertension, diabetes) were all recorded if any. 2. Filling out the Female Sexual Function Index (FSFI) Questionnaire Participant females were interviewed privately and confidentially by a female investigator using the and Ar- abic translated and validated 19- item structured FSFI questionnaire [11-13]. The FSFI uses six item separate domains to assess sex- ual functioning in women (desire, arousal, lubrication, Conclusions: Sexual dysfunction should be routinely investigated in female patients with psoriasis in the case of moderate-severe disease due to its negative impact on quality of life. Further research over the effect of certain interventional programs on FSD should be considered for patients suffering from psoriasis. Original Article | Dermatol Pract Concept. 2023;13(3):e2023209 3 orgasm, satisfaction, pain) with a total score of 26.5 de- termined as the cutoff score to distinguish between nor- mal and abnormal sexual dysfunction. 3. Calculating Psoriasis Area Severity Index (PASI) To calculate PASI, the body was divided into four ar- eas (head (H) (10% of a person’s skin); arms (A) (20%); trunk (T) (30%); legs (L) (40%). By adding up each areas score a final PASI value is reproduced with a maximum value of 72 which means a 100% body involvement. Scores below 10 mark mild psoriasis and scores above 20 are regarded as severe while scores falling between 10 and 20 are regarded as moderate psoriasis. In the cur- rent cross-sectional study, only females aged 18-40 with moderate to severe plaque psoriasis (BSA ≥ 10%) were included. Statistical Analysis Statistical package for social sciences (SPSS) 26 was used for providing, mean SD of quantitative data and categori- cal data. Kruksal-Wallis and Mann-Whitney tests were used for non-parametric data and linear regressions were iden- tifies. P values of less than 0.05 were reported statistically significant. Results Socio-Demographic and Metabolic Characteristics In the present study, female patient ages ranged from 18 to 40 years with a statistically significant increase of age among severe PASI patients (33.51 ± 2.08) when compared to ei- ther moderate PASI group (26.32 ± 6.01) or control group (29.84 ± 6.09). No significance in age was determined be- tween moderate PASI females and (P = 0.38) (Table1). BMI increased significantly among severe PASI psoriatic patients (29.12 ± 2.76) when compared to either moderate PASI patients (26.63 ± 2.87) or control group (23.97 ± 1.39). On the contrary a significant decrease in BMI was observed among moderate PASI females when compared to controls (Table 1). Disease duration in females suffering from psoriasis ranged from 1 to 27 years and was significantly less in mod- erate PASI females when compared to those with severe PASI (3.51 ± 2.52 versus 13.12 ± 6.17 respectively; P < 0.001). Psoriasis patients age at disease onset ranged from 14 to 39 years and was significantly lower among severe PASI group when compared to moderate PASI and control group (P < 0.001). Table 1. Demographic characteristics of studied subjects. Age Mean SD Minimum Maximum P values Moderate PASI 26.32 6.01 18.00 40.00 P1<0.001 P2 = 0.48 P3 <0.001 Severe PASI 33.51 2.08 28.00 40.00 Control 29.84 6.09 18.00 40.00 Total 30.57 6.00 18.00 40.00 BMI Mean SD Minimum Maximum P values Moderate PASI 26.63 2.87 21.40 32.90 P1<0.001 P2 <0.001 P3< 0.001 Severe PASI 29.12 2.76 25.50 37.40 Control 23.97 1.39 20.40 27.05 Total 27.03 3.25 20.40 36.98 Disease Duration Mean SD Minimum Maximum P Moderate PASI 3.51 2.52 1.00 11.00 < 0.001Severe PASI 13.12 6.17 4.00 27.00 Total 8.09 6.66 1.00 27.00 Age at disease onset Mean SD Minimum Maximum P value Moderate PASI 29.06 4.41 29.00 39.00 <0.001Severe PASI 21.75 2.34 14.00 36.00 Total 22.13 7.34 14.00 39.00 BMI = body mass index; PASI = Psoriasis Area and Severity Index; SD = standard deviation. 4 Original Article | Dermatol Pract Concept. 2023;13(3):e2023209 was significantly decreased arousal among moderate PASI females when compared to control group (P < 0.05). Lubrication decreased significantly among those with se- vere PASI (3.14 ± 0.79) when compared to moderate PASI group or controls (3.82 ± 0.69; 4.29 ± 0.64 respectively) and was significantly decreased in those with moderate PASI when compared to controls. Orgasm decreased significantly among those with severe PASI (3.50 ± 0.98) when compared to moderate PASI group Prevalence and Types of FSD Desire scores ranged from 1.27 to 6 and were significantly lower in those with severe PASI (3.42 ± 1.27) when com- pared to either those with moderate PASI or controls (4.23 ± 0.64 and 4.99 ± 0.59, respectively) (Table 2). Arousal scores ranged from 1.46 to 5.38 and were sig- nificantly lower in those with severe PASI (3.49 ± 1.03) when compared to either those with moderate PASI or controls (4.47 ± 0.42 and 4.94 ± 0.59, respectively). In addition, there Table 2. Female Sexual Function Index domain and total scores. Desire Mean SD Minimum Maximum P values Moderate PASI 4.23 0.64 2.45 5.48 P1 < 0.001 P2 < 0.001 P3 < 0.001 Severe PASI 3.42 1.27 1.27 4.89 Control 4.99 0.59 3.67 6.00 Arousal Mean SD Minimum Maximum P value Moderate PASI 4.47 0.42 3.25 5.38 P1 < 0.001*P2 = 0.001*P3 <0.001*Severe PASI 3.49 1.03 1.46 4.69 Control 4.94 0.59 3.68 5.73 Lubrication Mean SD Minimum Maximum P value Moderate PASI 3.82 0.69 2.3 5.17 P1 < 0.001 P2 <0.001 P3 = 0.006 Severe PASI 3.14 0.79 1.47 4.24 Control 4.29 0.64 3.50 5.69 Orgasm Mean SD Minimum Maximum P values Moderate PASI 3.99 0.77 2.30 5.10 P1 = 0.007 P2 < 0.001 P3 = 0.017 Severe PASI 3.50 0.98 1.60 4.60 Control 4.42 0.58 2.80 5.80 Satisfaction Mean SD Minimum Maximum P value Moderate PASI 5.19 0.40 4.10 5.50 P1 = 0.90(ns) P2 = 0.75(ns) P3=0.86 (ns) Severe PASI 5.08 0.67 3.20 5.40 Control 5.14 0.32 4.30 6.00 Dyspareunia (painful intercourse) Mean SD Minimum Maximum P values Moderate PASI 4.61 0.55 3.50 6.00 P1 <0.001 P2 < 0.001 P3 = 0.007 Severe PASI 4.88 0.68 3.20 6.00 Control 3.94 0.97 1.70 5.20 Total score Mean S. D Minimum Maximum P value Moderate PASI 26.24 2.67 20 29.70 P1 < 0.001 P2 < 0.001 P3 = 0.015 Severe PASI 22.34 5.35 12.30 28.30 Control 28.79 2.22 22.30 34.20 FSD = female sexual dysfunction; ns = not significant; PASI = Psoriasis Area and Severity Index; SD = standard deviation. Original Article | Dermatol Pract Concept. 2023;13(3):e2023209 5 showed significant associations, none of them showed to be a risk factor for FSD (P = 0.78 and P = 0.64, respectively), while psoriasis severity and its duration were risk factors for development of FSD in the studied females (P < 0.001 and P  = 0.04, respectively) (Table 4). Conclusions Sexual health is essential for physical and psychological well-being. A number of factors had been related to sexual dysfunction among patients suffering from psoriasis, yet the exact mechanism remains to be fully elucidated [4,5]. In our study model using FSFI, we identified the prev- alence of sexual dysfunction to be significantly higher in both severe and moderate PASI groups (52.0 and 30.0%, respectively) than in the control group (10%). This finding is consistent with results obtained by Nassar et al. who found the prevalence of FSD to be higher among psoriatic females than controls and determined the existence of a correlation between psoriasis severity and FSD [15]. A major systemic literature review of sexual dysfunction in patients with psoriasis, psoriatic arthritis as well as rheu- matoid arthritis assessed 1472 females with ages ranging from 23 to 62 years and found prevalence rates in all studies to vary from 22.6% to 71.3%. An Italian multicenter case control study demonstrated a higher prevalence of sexual or controls (3.99 ± 0.77 and 4.42 ± 0.58, respectively) and was significantly decreased in those with moderate PASI when compared to controls. Satisfaction scores showed no significant difference among all study groups despite being lower among psoriatic patients. Dyspareunia was significantly reduced in control group (3.94 ± 0.97) when compared to Severe PASI group (4.88 ± 0.68) or moderate PASI group (4.61 ± 0.55). In addition, pain score was insignificantly lower in moderate PASI pa- tients when compared to the severe PASI group. Considering the total FSFI score which ranged from 12.30 to 34.20, a significant reduction was observed among severe PASI females (22.34 ± 5.35) when compared to ei- ther moderate PASI patients or controls (26.24 ± 2.67 and 28.79  ± 2.22, respectively) and in moderate PASI females when compared to the control group. Female sexual dysfunction determined by a cutoff score < 26.55 was significantly higher in patients with severe PASI (58.0%) when compared to moderate PASI patients or con- trol group (36.0% and 24.0%, respectively). In addition, there was significant increase of FSD among moderate PASI patients compared to controls (Table 3). Risk Factors for FSD Psoriasis regardless of its severity (odds ratio 1.33; CI 1.16-1.52) significantly affected 47.0% of females com- pared to 24.0% among controls and was determined a risk factor for FSD. Patients complaining of FSD had a significantly earlier disease onset with longer duration when compared with nor- mal controls while BMI showed no significant correlation. Running logistic regression to examine if any of signif- icant associations is a risk factor when considering all fac- tors together, age, and age of onset of psoriasis, although Table 3. Incidence and prevalence of female sexual dysfunction in the studied groups. Incidence of female sexual dysfunction in studied groups Moderate PASI Severe PASI Control Total N % N % N % N % FSD Positive (< 26.55) 18 36.0% 29 58.0% 12 24.0% 59 39.3% Negative 32 66.0% 21 42.0% 38 76.0% 91 60.7% P values P1 = 0.008; P2 = 0.013, P3 <0.001 Prevalence of FSD among psoriatic patients versus controls Psoriatic (100) Control group (50) P valueN % N % FSD FSD (<26.55) 47 47.0 12 24.0% < 0.001*No FSD 53 53.0 38 76.0% Risk estimate Odds ratio = 1.33, 95% CI (1.16- 1.52) CI = confidence interval; FSD = female sexual dysfunction; PASI = Psoriasis Area and Severity Index. Table 4. Logistic regression analysis for prediction of sexual dysfunction. Predictors β P Age -1.76 0.78 Duration 0.27 0.04 Psoriasis severity 17.89 < 0.001 6 Original Article | Dermatol Pract Concept. 2023;13(3):e2023209 A recent metanalysis of eight studies including 563 women with psoriasis and 525 controls identified signifi- cantly impaired sexual function in women with psoriasis compared to controls, suggesting that routine assessment of sexual health may be beneficial [31]. Identifying and communication about a subject histori- cally regarded a taboo in middle eastern culture is a major strength of this study. The only reliance on a questionnaire and lack of hormonal or clitoral doppler sonography in a limited population sample is a limitation to the current study. Sexual health and dysfunction and their impact on qual- ity of life should be part of the integral routine investigation for females complaining of psoriasis. Further research over the effect of certain interventional programs on FSD should be considered for patients suffering from psoriasis. Larger multicenter studies investigating the sexual well-being of fe- males affected by chronic conditions should be considered for better assessment and understanding how such condition could impact and hinder their quality of life and provide in- sights on how to alleviate any dysfunctions. References 1. Obaid ZM, Amer AW, Zaky MS, et al. Prevalence of female sex- ual dysfunction among diabetic females: a cross-sectional case controlled study. Postgrad Med. 2022;134(7):680-685. DOI: 10.1080/00325481.2022.2102842. PMID: 35838136. 2. Boone D, Ronson A, Karsh J. Comparison of Female Sexual Func- tion Index in patients with psoriatic and rheumatoid arthritis and healthy controls. Musculoskeletal Care. 2019;17(3):226-230. DOI: 10.1002/msc.1405. PMID: 31219665. 3. Caputo V, Strafella C, Termine A, et al. Overview of the molecular determinants contributing to the expression of Psoriasis and Pso- riatic Arthritis phenotypes. J Cell Mol Med. 2020;24(23):13554- 13563. DOI: 10.1111/jcmm.15742. PMID: 33128843. PMCID: PMC7754002. 4. Caputo V, Strafella C, Cosio T, et al. Pharmacogenomics: An Up- date on Biologics and Small-Molecule Drugs in the Treatment of Psoriasis. Genes (Basel). 2021;12(9):1398. DOI: 10.3390/ genes12091398. PMID: 34573380. PMCID: PMC8470543. 5. Duarte GV, Calmon H, Radel G, de Fátima Paim de Oliveira M. Psoriasis and sexual dysfunction: links, risks, and management challenges. Psoriasis (Auckl). 2018;8:93-99. DOI: 10.2147/PTT .S159916. PMID: 30574453. PMCID: PMC6292237. 6. Alariny AF, Farid CI, Elweshahi HM, Abbood SS. Psychologi- cal and Sexual Consequences of Psoriasis Vulgaris on Patients and Their Partners. J Sex Med. 2019;16(12):1900-1911. DOI: 10.1016/j.jsxm.2019.08.017. PMID: 31542353. 7. Reebye P. Psychodermatology: The Psychological Impact of Skin Disorders. J Can Acad Child Adolesc Psychiatry. 2008;17(3): 169–171. PMCID: PMC2527778. 8. Hassanin IM, Helmy YA, Fathalla MM, Shahin AY. Preva- lence and characteristics of female sexual dysfunction in a sample of women from Upper Egypt. Int J Gynaecol Obstet. 2010;108(3):219-223. DOI: 10.1016/j.ijgo.2009.09.031. PMID: 20006846. dysfunctions in moderate-severe psoriatic patients aged be- low 46 years when compared to healthy controls [16]. In the present study, the prevalence of sexual dysfunction in the control group (24.0%) is slightly lower than the values found in other studies with healthy Egyptian women, where prevalence varied from 30% to 34.7%. This could be explained by the different epidemiological profiles of the study groups and the fact that women with chronic diseases, except for ar- thritis, or chronic drug use were not excluded [17,18]. Sexual difficulties among different ethnic groups can be related to dif- ference in culture, habits as well as religious attitudes. In our Egyptian community, the conservative beliefs and traditions can influence discussing sexual problems openly and could result in underreporting the existence of any especially among rural communities due to perceived cultural and religious restraints. We demonstrated a significant difference between psori- asis group and control group regarding desire, arousal, lu- brication, orgasm, satisfaction and pain domain scores. This comes in agreement with a number of studies that demon- strated significant sexual dysfunction affection among all domains in psoriatic patients [19-22]. This was in contrary to Khaled et al. who reported no significant difference be- tween psoriasis group and control group regarding desire, arousal, lubrication, and pain domain scores [17]. Our results indicated that psoriatic females with FSD had a significantly older age, longer disease duration, and earlier age of disease onset when compared to those with no FSD. This was verified and agreed on by a number of researchers who indicated that older women with earlier onset of pso- riasis demonstrated a lower sexual dysfunction and are at more risk of poor sexual quality of life [17,23,24]. This was not the case with other studies that reported no significant relation between age of psoriatic female patient and sexual activity (with P = 0.3; P = 0.7) [15,19,25]. Although our findings showed a significant negative as- sociation between BMI and FSD among psoriatic patients when compared to controls, this correlation was statistically insignificant (P = 0.20) when correlating predictor factors to development of FSD among psoriasis patients. Our finding agrees with previous studies that could not consolidate an association between BMI and sexual functions [5,6]. While other contradicting results showed a recognizable negative correlation between BMI and sexuality [6]. It is worth men- tioning that our results could have been affected by lack of hormonal check-up, investigations for insulin resistance, metabolic syndrome as well as failure of assessment of blood flow to the genitalia as well as the small sample size. Our findings regarding the association between impaired sexual function and severity of psoriasis were consistent with previously published data [26-30]. In contrary to our results, Turel et al showed no significant correlation between PASI score and sexual activity (with P = 0.4) [19]. Original Article | Dermatol Pract Concept. 2023;13(3):e2023209 7 21. Kwan Z, Baharum N, Yong SS, Mohd Affandi A, Johar A. Sexual difficulties and associated factors among patients with psoriasis in Malaysia: data from the Malaysian Psoriasis registry. Psychol Health Med. 2022;27(5):1011-1020. DOI: 10.1080/13548506.2020.1831557. PMID: 33044840. 22. Ermertcan AT. Sexual dysfunction in dermatological diseases. J Eur Acad Dermatol Venereol. 2009;23(9):999-1007. DOI: 10.1111/j.1468-3083.2009.03139.x. PMID: 19250323. 23. Meeuwis KA, de Hullu JA, van de Nieuwenhof HP, et al. Qual- ity of life and sexual health in patients with genital psoriasis. Br J Dermatol. 2011;164(6):1247-1255. DOI: 10.1111/j.1365- 2133.2011.10249.x. PMID: 21332459. 24. Kimball AB, Gieler U, Linder D, Sampogna F, Warren RB, Au- gustin M. Psoriasis: is the impairment to a patient's life cumula- tive? J Eur Acad Dermatol Venereol. 2010;24(9):989-1004. DOI: 10.1111/j.1468-3083.2010.03705.x. PMID: 20477920. 25. Fortune DG, Richards HL, Main CJ, Griffiths CE. Pathological worrying, illness perceptions and disease severity in patients with psoriasis. Br J Health Psychol. 2000;5:71–82. 26. Mostafa AM, Khamis Y, Helmy HK, Arafa AE, Abbas AM. Prevalence and patterns of female sexual dysfunction among overweight and obese premenopausal women in Up- per Egypt; a cross sectional study. Middle East Fertility So- ciety Journal 2018; 23(1):68-71. https://doi.org/10.1016/j. mefs.2017.08.006 27. Yaylali GF, Tekekoglu S, Akin F. Sexual dysfunction in obese and overweight women. Int J Impot Res. 2010;22(4):220-226. DOI: 10.1038/ijir.2010.7. PMID: 20485360. 28. Molina-Leyva A, Jiménez-Moleón JJ, Naranjo-Sintes R, Ruiz-Carrascosa JC. Sexual dysfunction in psoriasis: a system- atic review. J Eur Acad Dermatol Venereol. 2015;29(4):649-655. DOI: 10.1111/jdv.12845. PMID: 25424331. 29. Guenther L, Han C, Szapary P, et al. Impact of ustekinumab on health-related quality of life and sexual difficulties asso- ciated with psoriasis: results from two phase III clinical trials. J Eur Acad Dermatol Venereol. 2011;25(7):851-857. DOI: 10.1111/j.1468-3083.2011.04082.x. PMID: 21521375. 30. Ruiz-Villaverde R, Sánchez-Cano D, Rodrigo JR, Gutierrez CV. Pilot study of sexual dysfunction in patients with psoriasis: influ- ence of biologic therapy. Indian J Dermatol. 2011;56(6):694-699. DOI: 10.4103/0019-5154.91831. PMID: 22345773. PMCID: PMC3276899. 31. Shah SFH, Merchant SA, Shah SA. Female sexual dysfunction in psoriasis: a systematic review and meta-analysis using the Female Sexual Function Index. Int J Impot Res. 2022. DOI: 10.1038/ s41443-022-00650-9. PMID: 36456639. 9. Mustafa AI, Mohamed El Esawy FM, Fawzy I. Female Sexual Dys- function Among Married Women from the Nile Delta of Egypt. International Journal of Sexual Health. 2019;31(2):131-141. DOI 10.1080/19317611.2019.1595257 10. Ibrahim ZM, Ahmed MR, Sayed Ahmed WA. Prevalence and risk factors for female sexual dysfunction among Egyptian women. Arch Gynecol Obstet. 2013;287(6):1173-1180. DOI: 10.1007 /s00404-012-2677-8. PMID: 23274790. 11. Rosen R, Brown C, Heiman J, et al. The Female Sexual Function Index (FSFI): a multidimensional self-report instrument for the assessment of female sexual function. J Sex Marital Ther. 2000;26(2):191-208. DOI: 10.1080/009262300278597. PMID: 10782451. 12. Abu Ali RM, Al Hajeri RM, Khader YS, Shegem NS, Ajlouni KM. Sexual dysfunction in Jordanian diabetic women. Diabetes Care. 2008;31(8):1580-1581. DOI: 10.2337/dc08-0081. PMID: 18458140. PMCID: PMC2494660. 13. Anis TH, Gheit SA, Saied HS, Al kherbash SA. Arabic trans- lation of Female Sexual Function Index and validation in an Egyptian population. J Sex Med. 2011;8(12):3370-3378. DOI: 10.1111/j.1743-6109.2011.02471.x. PMID: 21995610. 14. Wiegel M, Meston C, Rosen R. The female sexual function in- dex (FSFI): cross-validation and development of clinical cut- off scores. J Sex Marital Ther. 2005;31(1):1-20. DOI: 10.1080 /00926230590475206. PMID: 15841702. 15. Nassar AA, Ibrahim AM, Salem HM. The effect of Psoriasis on Female Sexual Function. The Egyptian Journal of Hospital Med- icine. 2021;84:1686-1689. DOI: 10.21608/EJHM.2021.175730 16. Bardazzi F, Evangelista V, Ferrara F, et al. Does psoriasis influence female sexual dysfunction? A multicentric Italian case-control study. Ital J Dermatol Venerol. 2022;157(5):432-435. DOI: 10.23736/S2784-8671.21.07128-0. PMID: 34545729. 17. Khaled HN, El-Sabagh EA, Bazid HA. Female sexual dysfunction in patients with psoriasis and vitiligo: an Egyptian pilot study. J Egypt Womens Dermatol Soc. 2021;18:22-34. DOI: 10.4103 /JEWD.JEWD_51_20 18. Maaty AS, Gomaa AH, Mohammed GF, Youssef IM, Eyada MM. Assessment of female sexual function in patients with psoriasis. J Sex Med. 2013;10(6):1545-1548. DOI: 10.1111/jsm.12119 . PMID: 23530657. 19. Türel Ermertcan A, Temeltaş G, Deveci A, Dinç G, Güler HB, Oztürkcan S. Sexual dysfunction in patients with psoria- sis. J Dermatol. 2006;33(11):772-778. DOI: 10.1111/j.1346 -8138.2006.00179.x. PMID: 17073992. 20. Frank E, Anderson C, Rubinstein D. Frequency of sexual dysfunc- tion in "normal" couples. N Engl J Med. 1978;299(3):111-115. DOI: 10.1056/NEJM197807202990302. PMID: 661870.