Iraqi J Pharm Sci, Vol.29(2) 2020 Quality of life among patients with psoriasis DOI: https://doi.org/10.31351/vol29iss2pp161-168 161 Assessment of Quality of Life in a Sample of Iraqi Patients with Psoriasis Sarah H. Abdulridha*, Dheyaa J. Kadhim**, Sarmad A. Abdul Razzak*** *The State Company for Marketing Drugs and Medical Appliances, Ministry of Health and Environment, Baghdad, Iraq. **Department of Clinical Pharmacy, College of Pharmacy, University of Baghdad, Baghdad, Iraq. ***Center of Dermatology and Venereology, Medical City, Baghdad, Iraq. Abstract Psoriasis is a dermatological, chronic, immune-mediated condition. Psoriasis symptoms are not associated with physical burden only, but it may also have psychosocial effects on patients, diminished cognitive control, poor body image and impairments in everyday life. The value of quality of life is important since improving it is the principal goal for non-curative disease. The aim of the current study was to evaluate quality of life in a sample of Iraqi patients with psoriasis. This study is a cross-sectional study that involved 300 already diagnosed psoriasis patients who attended to the center of Dermatology and Venereology, Medical City/Baghdad. The mean age of patients was (35.156 ±10.549 years). The Arabic version of Dermatology Life Quality Index was used to assess quality of life. The mean total score is 11.29± 5.45 and the majority of the patients (53.7%) had a total score of more than 10, which indicates a significant deterioration in patients’ quality of life. The greatest impact was found in symptoms and feelings (mean = 1.66 ± 0.75) while the lowest impact was noted in personal relationships (0.51± 0.65). Increasing age and monthly income as well as vulgaris type of psoriasis associated significantly better quality of life. While Psoriasis Area and Severity Index associated significantly worse quality of life. In conclusion, psoriasis exerts significant, negative impact on patients’ quality of life, especially among those with younger age, lower monthly income, high disease activity, and types of psoriasis other than vulgaris. Keywords: Psoriasis, Iraq, Dermatology life quality index, Quality of life, Psoriasis area and severity index. تقييم نوعية الحياة لدى عينة من المرضى العراقيين المصابين بالصدفية. ***سرمد عدنان عبد الرزاق ،**جبار كاظم ، ضياء1*،عبد الرضاسارة حيدر العراق. ،، بغدادالصحة والبيئة ، وزارة الشركة العامة لتسويق االدوية والمستلزمات الطبية * .، بغداد، العراقبغداد ، جامعةالصيدلة ، كلية السريرية الصيدلة فرع** *** الطب، بغداد، العراق. ، مدينةمركز االمراض الجلدية والزهرية الخالصة تأثيرات نفسية أيًضا لها يكون أن يمكن بل توهن الجسد فحسب، ال الصدفية أعراض إن. مناعي المنشئ مزمن جلدي مرض هي الصدفية لألمراض الرئيسي الهدف هو تحسينها حيث ان مهمة جودة الحياة قيمة إن .وكذلك تأثير سلبي على منظر الجسم والفعاليات اليوميةعاطفية و اجتماعيةو عبارة الدراسة هذه. بالصدفية المصابين العراقيين المرضى من عينة لدى الحياة جودة تقييم هو الحالية الدراسة من الهدف كان. القابلة للشفاء غير /الطب مدينة والزهرية، الجلدية األمراض إلى مركز حضروا المشخصين مسبقا والذين الصدفية مرضى من 300 على أجريت مقطعية دراسة عن لألمراض الحياة جودة دليل من العربية النسخة باستخدام الحياة جودة تقييم تم(. سنة 10.549± 35.156)هو المرضى عمر متوسط كان. بغداد إلى يشير مما ، 10 من أكثر نقاط مجموع على٪( 53.7) المرضى غالبية وحصلت ، 5.45± 11.29 هو الكلية الدرجة كان متوسط. الجلدية العالقات في تأثير أقل لوحظ بينما( 0.75± 1.66= المتوسط) والمشاعر األعراض في األكبر األثر ولوحظ. شديد في جودة حياة المرضى ضعف بينما. أفضل حياة ملموس بنوعية بشكل يرتبط الشائع الصدفية نوع إلى باإلضافة الشهري والدخل العمر ان زيادة(. 0.65± 0.51) الشخصية المرضى، حياة جودة على كبير سلبي تأثير لها الصدفية فإن كنتيجة أسوء. حياة بنوعية ملموس بشكل الخطورة ومؤشر الصدفية منطقة ارتبطت .النوع الشائع غير االخرىالصدفية وأنواع مرتفع، ونشاط مرضي الشهري المنخفض، واصحاب الدخل سنا، أصغر هم الذين أولئك بين خاصة . العراق الخطورة، ومؤشر الصدفية منطقة الجلدية، لألمراض الحياة جودة مؤشر الحياة، جودة الصدفية،: المفتاحية الكلمات Introduction Psoriasis is a chronic, inflammatory condition that primarily affects the skin, hair, and the joints and associated with a significant humanistic and economic consequences (1, 2). It occurs in about 1% to 3% worldwide, (3) with higher prevalence in western countries. (4) The precise cause of psoriasis stills unclears (5). Psoriasis is closely related to genetics, but environmental exposure plays an essential role in the disease development. (4) Obesity is another risk factor for psoriasis (6). Many medicinal and chemical products, have been found to be related to the triggering and/or exacerbation of psoriasis including beta-adrenergic receptor blockers and tetracycline (7,8). 1Corresponding author E-mail: sarahaider801@gmail.com Received:15 /3 / 2020 Accepted: 14/ 6/2020 Iraqi Journal of Pharmaceutical Science https://doi.org/10.31351/vol29iss2pp161-168 Iraqi J Pharm Sci, Vol.29(2) 2020 Quality of life among patients with psoriasis 162 Psoriasis is stimulated by the abnormal epidermal proliferation, leading to scaly erythematous plaques. (9) The pathophysiology of psoriasis includes an interplay between elements of the immune response, inflammatory components and an abnormal proliferation and differentiations of the keratinocytes, (10) results in scaly erythematous plaques. (9) Psoriasis has many different clinical presentations. The classic one is of red plaques and silver scale, (11) associated symptoms of itch, burning and soreness. (12) Psoriasis is classified as mild, moderate, or severe, relying on the percentage of the affected body surface area (BSA) and the Psoriasis Area and Severity Index (PASI). (13) The aims of treating psoriasis are to get an initial and fast control for disease symptoms, decrease the percentage of involved BSA, decrease plaque lesions, minimize adverse drug events, produce and maintain long-term remission, and improve the patient’s quality of life (QOL). (11) Selection of treatment in patients with psoriasis depends on disease severity, (14) the presence of comorbid conditions, such as psoriatic arthritis, and treatment history. (15) Topical treatments are generally used as first-line therapy for most types of psoriasis (16) and include tar preparations, corticosteroids, calcipotriene, adarotene and anthralin. (11) Moderate- to-severe psoriasis is usually treated by using systemic therapies. Methotrexate and biologics are the most-used systemic treatments for psoriasis. (17) Biologics are often the next step in the treatment when conventional systemic therapies fail or are contraindicated. (17) Biologics are very effective potent immunomodulatory drugs. (18) They are generally considered safe drugs but may be associated with rare serious adverse reactions such as malignancy and reactivation of tuberculosis. (19) The World Health Organization defined QOL as “the individuals ‘perceptions of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns.” (20) The QOL's value is important for knowing what is significant to the individuals’ QOL since the principal goal for non-curative disease is to improve QOL. (21) Psoriasis can have a significant impact on patients’ QOL and work productivity, depending on disease severity. (22) Symptoms of psoriasis are not limited to physical impact, they can also have strong psychosocial effects, (23) resulting in impaired emotional state, daily activity, and body image. (24) Accordingly, the aim of the current study was to evaluate QOL in a sample of Iraqi psoriatic patients and to determine possible association between QOL and some patient’s related factors. Patients The current study was a cross-sectional study that involved 300 already diagnosed psoriasis patients (mean age was 35.16 ±10.55 years) who attended to the Center of Dermatology and Venereology, Medical City/Baghdad from October 2019 to January 2020. The number of male patients was 188 (62.67%), while the number of female patients was 112 (37.33%). Inclusion criteria 1-Patients age ≥ 18 years who willing to participate in the study. 2-The duration of the disease is ≥ 6 months. 3-Prescribed pharmacological treatment for psoriasis. Exclusion criteria 1- Patient with cognitive, speech, or a hearing deficits that would affect questions’ understanding. 2-Patient with other skin disorders. 3-Concomitant other significant diseases (such as diabetes mellitus, hypertension, chronic lung disease, chronic renal failure, heart disease and stroke). 4-Pregnant or lactating women. 5-Patients who provide incomplete information. Method The questionnaires The QOL was assessed by using the Arabic version of Dermatology Life Quality Index (DLQI). The DLQI is a validated, dermatology-specific QOL instrument that was developed in the early 1990s, (25,26) and has been used in several trials for psoriasis, (25) The DLQI questionnaire consists of 10 questions, subdivided into 6 domains related to various aspects of a person's QOL: symptoms and feelings (questions one and two), daily activities (questions three and four), leisure (questions five and six), work/school (question seven), personal relationships (questions eight and nine), and treatment (question ten). Higher scores indicate greater deterioration of the patient's QOL and vice versa. (27) Total DLQI score between 0 and 1 indicates no effect on patient's QOL, 2–5 small effect, 6–10 moderate effect, 11–20 very large effect, and 21–30 indicates extremely large effect on patients' QOL. (14) Administration of the questionnaires When the patients arrived to the Center of Dermatology and Venereology for checkup and to receive their medications, they were interviewed by the researcher and asked if they are willing to participate in the current study, if they agreed, then a clarification of the questionnaire was given and each patient allowed to fill the research questionnaire which takes about 5-10 minutes to be filled completely. Statistical analysis The analyses were done by using the Statistical Package for the Social Science (SPSS, version 22, IBM, New York, USA). Descriptive statistics (means, standards deviations, frequencies and percentages) of the participants and disease Iraqi J Pharm Sci, Vol.29(2) 2020 Quality of life among patients with psoriasis 163 were calculated. Multiple linear regression was used to measure the association between total DLQI score and multiple independent variables (socio- demographic and disease characteristics). Results Sociodemographic features of patients are represented in the Table 1. Table 1. The sociodemographic features of the patients Item Subcategor y Frequenc y (N) % Gender Male 188 62.7 Female 112 37.3 Education level Illiterate 20 6.7 Primary school 84 28.0 Secondary school 104 34.7 College degree 92 30.7 Social status Single 80 26.7 Married 207 69.0 Divorced 8 2.7 Widow 5 1.7 Having children Yes 106 35.3 No 194 64.7 Living Place Rural 46 15.3 Urban 254 84.7 Work Status Employee 92 30.7 Student 26 8.7 Retired 91 30.3 Self- employed 6 2.0 Wife House 85 28.3 Monthly income (Iraqi million dinars) < 0.5 117 39.1 0.5-1.0 84 28.1 > 1.0 98 32.8 Smoker Yes 84 28.0 No 216 72.0 Alcohol drinker Yes 17 5.7 No 283 94.3 The most common type of psoriasis was vulgaris (77.7%) which followed by erythrodermic and psoriatic arthritis types (6.3%) (Figure 1). V u l g a r i s E r y t h r o d e r m i c P s o r i a t i c a r t h r i t i s P u s t u l a r G u t t a t e P a l m o p l a n t a r G e n i t a l 0 2 0 4 0 6 0 8 0 1 0 0 P s o r i a s i s T y p e s % o f p a ti e n ts 7 7 . 7 % 6 . 3 % 6 . 3 % 4 . 0 % 3 . 7 % 1 . 7 % 0 . 3 % Figure 1. The types of psoriasis affected the participating patients The most commonly used medications to treat psoriasis were topical steroids (63%), systemic etanercept (biological therapy) (61.7%) and vaseline (41.3%) (Table 2). Table 2. The prescribed medications to treat psoriasis Medication Frequency (N) Percent (%) Topical steroids 189 63.0 Vaseline 124 41.3 Phototherapy 7 2.3 Cinnamon shampoo 6 2.0 Zinc oxide ointment 6 2.0 Topical calcineurin inhibitors 3 1.0 Topical coal tar 2 0.7 Systemic treatment Etanercept 185 61.7 Methotrexate 68 22.7 Folic acid 68 22.7 Cyclosporine 17 5.7 Acitretin 5 1.7 Antihistamines 6 2 Isoniazid 1 0.3 Aprelimast 1 0.3 Adalimumab 1 0.3 Although the averages PASI and BSA were not high, the psoriasis had very large effect on about half of the patient (49.3%) quality of life (average DLQI=11.29) (Table 3 and Figure 2). Table 3 Descriptive characteristics of the disease and patients. Characteristic Minimum Maximum Mean Std. Deviation Disease duration (years) 0.5 43.0 13.12 8.60 Total DLQI 0 25.0 11.29 5.45 Severity index (PASI) 0.5 36.0 8.74 7.15 )2Body surface area (m 1.0 90.0 17.25 17.39 Total N=300. DLQI =Dermatology Life Quality Index. PASI =Psoriasis area severity index.. Iraqi J Pharm Sci, Vol.29(2) 2020 Quality of life among patients with psoriasis 164 0 1 0 2 0 3 0 4 0 5 0 6 0 N o e f f e c t s m a l l e f f e c t M o d e r a t e e f f e c t V e r y L a r g e e f f e c t E x t r e m e l y L a r g e e f f e c t % o f p a t i e n t s A f f e c t i n g Q O L 1 . 7 % 1 3 . 3 % 3 1 . 3 % 4 9 . 3 % 4 . 3 % Figure 2. Effects of the disease severity on patient quality of life The total scores with their sub-scores of patient’s DLQI are shown in Table 4. Since the average of total DLQI scores was more than 10 (11.2±5.49), that indicates that the patient's QOL is being seriously impacted by their skin disease. Table 4. The means of Dermatology Life Quality Index (DLQI) Item Mean Std. Deviation “Symptoms and feelings” 1.66 0.75 “Daily activities” 1.5 1.52 “Leisure activities” 0.71 0.77 “Going to work and school” 0.63 0.66 “Personal relationships” 0.51 0.65 “Treatment difficulties” 1.61 0.97 “Total DLQI score” 11.20 5.49 According o DLQI, more than half of the participants experienced itchy, sore, painful, stinging skin (55.7%) and/or embarrassment due to the skin disease (56.0%) in the last week. Consequently, the skin disease (psoriasis) negatively impacted many patients’ daily activities (48.3%), clothes wearing (63.4%) and even social/leisure activities (36.6%). Additionally, psoriasis disease prevented about one-quarter of the patients from going to work or studying (23%) and caused work/study problems for another third (34.7%) of the participants. More than half of the participants admitted that psoriasis made their home messy (57.3%) over the last week. However, the disease had low impact on patients’ sexual activities (8.7%) and their relations with close friends (20%) (Table 5). Table 5. Patients answers to dermatology Life Quality Index (DLQI) Disease consequences in the last week Not at all, N (%) A little, N (%) A lot, N (%) Very much, N (%) Not relevant, N (%) Itchy, sore, painful or stinging skin 17 (5.7) 116 (38.7) 104 (34.7) 63 (21.0) - Embarrassment due to the skin disease 51 (17.0) 81 (27.0) 102 (34.0) 66 (22.0) - Skin interference with shopping or looking after home/garden 67 (22.3) 88 (29.3) 109 (36.3) 36 (12.0) - Skin influences the clothes wearing 53 (17.7) 57 (19.0) 125 (41.7) 65 (21.7) - Skin effects on any social or leisure activities 113 (37.7) 76 (25.3) 64 (21.3) 46 (15.3) 1 (0.3) Skin influences on sport/exercise 75 (25.0) 31 (10.3) 20 (6.7) 10 (3.3) 164 (54.7) Skin prevents you from working/ studying. No 144 (48.0) Yes 69 (23.0) 87 (29.0) Skin causes a problem at work/ studying 94 (65.3) 39 (27.1) 11 (7.6) - Skin creates problems with your partner or any close friends/ relatives 179 (59.9) 55 (18.4) 47 (15.7) 13 (4.3) 5 (1.7) Skin causes any sexual difficulties 149 (49.8) 44 (14.7) 15 (5.0) 11 (3.7) 80 (26.8) The treatment for your skin making your home messy 47 (15.7) 79 (26.3) 115 (38.3) 57 (19.0) 2 (0.7) Iraqi J Pharm Sci, Vol.29(2) 2020 Quality of life among patients with psoriasis 165 Multiple linear regression analyses were used to measure the association between different socio- demographic and disease characteristics (independent variables) and total DLQI score (dependent variables) of the participants. Age, monthly income and vulgaris type of psoriasis have significant negative association with total DLQI score. While PASI has significant positive association with the total DLQI score (Table 6). Table 6. Association of total DLQI score with socio-demographic and disease characteristics variables of the participants BSA=Body surface area; PASI (Psoriasis Area Surface Index). *Significant association (P-value < 0.05). Gender (0=female vs 1 =male). NS=non- significant (P-value > 0.05). We excluded some highly non-significant variables (P-value > 0.6) (without mentioning ß) in some regression analyses to fit the model better. Types of psoriasis is binary variable = (0= non-vulgaris / 1= vulgaris). Discussion Psoriasis is a serious dermatological disease extending beyond the physical symptoms experienced by the patient, and seriously affecting the way in which the patient sees him /herself and the way he/she is seen by others. (28) In general, the commonly used measures of psoriasis activity are PASI and BSA. (29) The most widely used QOL questionnaire is the DLQI which is short and easy to use. (30) In the current study, more than one-half (53.7%) of the patients had a DLQI score of more than 10, which is more than that reported by a study done by Azura Mohd. et. al, where about 33.1% of patients had a DLQI score greater than 10, (4) which indicates a more deterioration in QOL for patients involved in the current study. The mean of total DLQI score is (11.29± 5.45) which is higher than that reported by Cacilda S. et. al, where the mean of DLQI score was (6.5 ± 6.9). (31) The largest impact was found in symptoms and feelings domain (mean score = 1.66±0.75). Similar findings were illustrated by Cacilda S. et. al, and Nilce´ia Lopes. et. al, where the greatest effect was noted for symptoms and feelings domain, asserting that emotion play an essential role in the QOL of patients with psoriasis, because the skin is largely responsible for an patient’s appearance. (1, 31) This mean that psoriasis has been associated with painful feelings of social anxiety and stigmatization, and fear of rejection. (32) The lowest impact was noted in personal relationships (score = 0.51± 0.65) which may be related to the fact that psoriasis is not contagious, so that the patient’s family and partner can help patients and encourage them to face the disease and come with them to doctor and take medication. In contrast to the result of the current study, a study done in Brazil by Nilce´ia Lopes. et. al., showed that the lowest impact was in work and school. (1) In addition, the majority of the studied patients did not feel embarrassed during sexual activities regardless of the disease severity which is similar to the result reported by Amany Youssef. et. al. (28) This may be due that most husbands (wives) understand the non-infectious nature of the disease and encourage their husbands(wives) to cure and recover. However; contrary to current results, Głowacka et. al., illustrated that psoriasis limit patients' sexual life because of their embarrassment (28). Studying the association between total DLQI score with various socio-demographic and disease characteristics variables of the participants revealed a significant negative association between age and total DLQI score (Table 6). Similar finding had been reported from a study done in Korea by Sang Woong Youn. et. al. (29) This may be explained by that younger patients pay more attention to their shape than elderly patients, so the disease effect on their QOL is greater. However; results of study done Total DLQI score ßeta Coefficients P-value Age -.135 .048* Gender NS social status .074 .273 Having children NS Educational level NS Living place NS Work status NS Monthly income -.161 .006* Smoker .067 .314 Alcohol drinker .043 .470 PASI 3.075 .002* )2BSA(m .301 .764 Face included 1.966 .050 Disease duration(yrs.) .340 .734 Types of psoriasis -.163 .005* Biologics .003 .959 Iraqi J Pharm Sci, Vol.29(2) 2020 Quality of life among patients with psoriasis 166 by Amany Youssef. et. al., illustrated that age played insignificant role. (28) Additionally, it was noted that patients with higher income was significantly associated with lower total DLQI score which mean better QOL (Table 6). Patients with higher monthly income can buy expensive medications which may be unavailable at public hospitals all the time and this might be reflected positively on their QOL. The results of this study showed a direct association between PASI and total DLQI score (Table 6), which is similar to the study done in Korea by Sang Woong Youn. et. al., where a greater impairment in QOL showed in patients with more severe psoriasis. (29) The predominant psoriasis type was plaque psoriasis (77.7%), which is consistent to the other studies done by Liliana G. et. al., (32) and Azura Mohd. et. al. (4), where the plaque psoriasis was the most common type of psoriasis. Vulgaris type of psoriasis has negative association with total score of DLQI, this means that vulgaris type has lower negative effect on QOL. This may be explained by the natural course of each type. For example, erythrodermic psoriasis is characterized by abrupt development of erythematous, inflammatory skin plaques with edema (33). Also the pustular type is a potentially life- threatening variant of psoriasis characterized by a sudden and widespread development of superficial pustules that lead to bad appearance and cause anxiety and restlessness. (34-36). In addition, psoriatic arthritis can cause irreversible damage to joints and supporting tissue. (37) which might be reflected negatively on quality of life of patients. Conclusions In conclusion, results of the current study document that psoriasis can exerts a significant, negative impact on patients’ QOL, especially among those with younger age, lower monthly income, high disease activity, and types of psoriasis other than vulgaris. Accordingly, routine assessment is recommended for patients with psoriasis to detect and monitor the impact of the disease and treatment on patients’ QOL with subsequent development of care plan to improve it especially in severely affected patients. Limitations of the study The first limitation was incorporating psoriatic patients from only one center in Baghdad city, so the data does not fully represent all Iraqi patients. In addition, the cross-sectional nature of the study makes it impossible to confirm causal conclusions. References 1. Lopes N, Dias L, Azulay-Abulafia L, Oyafuso L, Suarez M, Fabricio L,et al., Humanistic and Economic Impact of Moderate to Severe Plaque Psoriasis in Brazil. Adv. Ther. 2019;36(10):2849–65. 2. Tollefson MM, Van Houten HK, Asante D, Yao X, Kremers HM. Association of psoriasis with comorbidity development in children with psoriasis. JAMA dermatology. 2018;154(3):286-92. 3. Ljubenovic M, Lazarevic V, Golubovic M, Binic I. Integrative Approach to Psoriasis Vulgaris. Holist. Nurs. Pract. 2018 ;1;32(3):133-9. 4. Mohd Affandi A, Khan I, Ngah Saaya N. Epidemiology and clinical features of adult patients with psoriasis in Malaysia: 10-year review from the Malaysian Psoriasis Registry (2007–2016). Dermatol. Res. Pract. 2018;2018. 5. Al-Dhalimi MA, Al-Sahlawee MM, Al- Esawee HK. Correlation of leptin with severity of plaque psoriasis in Iraqi male patients. Journal of University of Babylon. 2016;24(5):1461-8. 6. Takeshita J, Grewal S, Langan SM, Mehta NN, Ogdie A, Van Voorhees AS, et al. Psoriasis and comorbid diseases: epidemiology. J. Am. Acad. Dermatol. 2017 ; 1;76(3):377-90. 7. Alidrisi HA, Al Hamdi K, Mansour AA. Is There Any Association Between Psoriasis and Hashimoto’s Thyroiditis?. Cureus. 2019;11(3). 8. Ahronowitz I, Fox L. Severe drug-induced dermatoses. Semin. Cutan. Med. Surg. 2014 ;33(1):49-58. 9. Kim SY, Min C, Oh DJ, Choi HG. Increased risk of psoriasis in children and elderly patients with asthma: a longitudinal follow‐up study using a national sample cohort. Int. Forum Allergy Rhinol. 2019 ; 9(11): 1304-1310. 10. Darjani A, Heidarzadeh A, Golchai J, Sadr- Eshkevari S, Alizadeh N, Arami M, et al. Quality of life in psoriatic patients: a study using the short form-36. Int. J. Prev. Med. 2014;5(9):1146. 11. Moradi M,et al.Health-related quality of life and disease burden of psoriasis in Iran [thesis]. Enschede:Corvinus University of Budapest  ,2017:1-168. 12. Damiani G, Cazzaniga S, Conic RR, Naldi L, Psocare Registry Network, Griseta V, et al. Pruritus characteristics in a large Italian cohort of psoriatic patients. J. Eur. Acad. Dermatology Venereol.. 2019;33(7):1316-24. 13. Mantovani L, Medaglia M, Piacentini P, Tricca M, Vena GA, Vozza A, Castellino G, Roccia A. Burden of moderate-to-severe plaque psoriasis and new therapeutic approaches (secukinumab): an Italian perspective. Dermatol. Ther. 2016;6(2):151-67. 14. Van de Kerkhof PC, Loewe R, Mrowietz U, Falques M, Pau‐Charles I, Szepietowski JC. Quality of life outcomes in adults with moderate‐to‐severe plaque psoriasis treated with dimethylfumarate (DMF): a post hoc analysis of the BRIDGE study. J. Eur. Acad. Dermatology Venereol.2020;34(1):119-26. Iraqi J Pharm Sci, Vol.29(2) 2020 Quality of life among patients with psoriasis 167 15. Martin G, Young M, Aldredge L. Recommendations for initiating systemic therapy in patients with psoriasis. J. Clin. Aesthet. Dermatol. 2019;12(4):13. 16. Aldredge LM, Higham RC. Manifestations and Management of Difficult-to-Treat Psoriasis. J. Dermatol. Nurses. Assoc. 2018;10(4):189-97. 17. Otero ME, Van Den Reek JM, Van De Kerkhof P, Mertens JS, Seyger M, Kievit W, et al Beliefs About Medicines in Patients with Psoriasis Treated with Methotrexate or Biologics: A Cross-sectional Survey Study. Acta Derm. Venereol. 2019;99(3):386-92. 18. Plachouri KM, Georgiou S. Challenges in the treatment of psoriasis with biologics: vaccination, history of malignancy, human immunodeficiency virus (HIV) infection, and pediatric psoriasis. Int. J. Dermatol. 2019;58(9):1008-13. 19. Ighani A, Yu AM, Sandhu VK, Barankin B, Manolson MF. Satisfaction and Awareness of Systemic Psoriasis Treatments: A National Survey Comparing Biologic and Nonbiologic Users. J. Cutan. Med. Surg. 2019;23(2):148- 56. 20. Hussein WA. The quality of life in patients with rheumatoid arthritis in Baghdad, 2017: a cross-sectional study. Int. J. Med. Res. Heal. Sci. 2017;6(11):20-34. 21. Al-ibrahimy AS and Al-Tukmagi HF. Assessing Quality of Life Among Patients with Diabetes Mellitus, Hypertension or Both Diseases in Al-Najaf Province/Iraq. Iraqi J Pharm Sci. 2017 ; 25:29-40. 22. Strober B, Greenberg JD, Karki C, Mason M, Guo N, Hur P, et al. Impact of psoriasis severity on patient-reported clinical symptoms, health-related quality of life and work productivity among US patients: real-world data from the Corrona Psoriasis Registry. BMJ open. 2019;9(4):e027535. 23. Wang H, Chan HH, Ni MY, Lam WW, Chan WM, Pang H. Bacteriophage of the Skin Microbiome in Patients with Psoriasis and Healthy Family Controls. J. Invest. Dermatol. 2020;140(1):182-90. 24. DiBonaventura M, Carvalho AV, Souza CD, Squiassi HB, Ferreira CN. The association between psoriasis and health-related quality of life, work productivity, and healthcare resource use in Brazil. Anais brasileiros de dermatologia. 2018;93(2):197-204. 25. Armstrong AW, Ford AR, Chambers CJ, Maverakis E, Dunnick CA, Chren MM, et al. Online Care Versus In-Person Care for Improving Quality of Life in Psoriasis: A Randomized Controlled Equivalency Trial. J. Invest. Dermatol. 2019;139(5):1037-44. 26. Rencz F, Brodszky V, Gulácsi L, Péntek M, Poór AK, Holló P, et al. Time to revise the Dermatology Life Quality Index scoring in psoriasis treatment guidelines. J. Eur. Acad. Dermatology Venereol 2019;33(7):e267-9. 27. Rastogi MK, Mohan R, Gahalaut P, Mishra N, Thapa M. Effect of topical steroid-dependent facial dermatitis on quality of life: A hospital- based cross-sectional study using DLQI. Indian J of dermatology. 2019;64(6):465-70. 28. Sharaf AY and Ibrahim AF. Quality of life of patients with Psoriasis in Alexandria-Egypt. IOSR J. Nurs. Heal. Sci.2017;6 (1):17–29. 29. Youn SW, Lee JH, Yu DY, Kim Y, Kim BS, Seo SJ, et al. The relationship between clinical characteristics including presence of exposed lesions and health‐related quality of life (HRQoL) in patients with psoriasis: analysis from the nationwide epidemiologic study for psoriasis in Korea (EPI‐PSODE study). Journal of the European Academy of Dermatology and Venereology. 2018;32(9):1499-506. 30. Lizán L, Gabás-Rivera C, Belinchón I, Dilla T, Huete T, Díaz S. Patient-reported outcomes assessment tools for use in psoriasis in Spain: A systematic review. Actas Dermo- Sifiliográficas,English Ed. 2019;110(7):561- 84. 31. Souza CS, de CASTRO CC, Carneiro FR, Pinto JM, Fabricio LH, Azulay‐Abulafia Let al. Metabolic syndrome and psoriatic arthritis among patients with psoriasis vulgaris: Quality of life and prevalence. J. Dermatol. 2019;46(1):3-10. 32. Jankovic S, Raznatovic M, Marinkovic J, Jankovic J, Kocev N, Tomic-Spiric V,et al. Health-related quality of life in patients with psoriasis. J. Cutan Med. Surg. 2011;15(1):29- 36. 33. Rendo M, Boster J, Dalton SR, Yun H. An Uncommon Presentation of Erythrodermic Psoriasis in a Patient Without a History of Psoriasis. Cureus. 2019;11(7). 34. Ly K, Beck KM, Smith MP, Thibodeaux Q, Bhutani T. Diagnosis and screening of patients with generalized pustular psoriasis. Psoriasis: Targets Ther. 2019;9:37-42. 35. Gooderham MJ, Van Voorhees AS, Lebwohl MG. An update on generalized pustular psoriasis Expert Rev. Clin. Immunol. 2019 2;15(9):907-19. Iraqi J Pharm Sci, Vol.29(2) 2020 Quality of life among patients with psoriasis 168 36. Twelves S, Mostafa A, Dand N, Burri E, Farkas K, Wilson R, et al. Clinical and genetic differences between pustular psoriasis subtypes. J. Allergy Clin. Immunol. 2019;143(3):1021-6. 37. Kaine J, Song X, Kim G, Hur P, Palmer JB. Higher incidence rates of comorbidities in patients with psoriatic arthritis compared with the general population using US administrative claims data. J Manag Care Spec Pharm. 2019;25(1):122-32. Creative Commons Attribution is licensed under a bijpsBaghdad Iraqi Journal Pharmaceutical Sciences by .University of Baghdad -Copyrights© 2015 College of Pharmacy .International License 4.0 http://creativecommons.org/licenses/by/4.0/ http://creativecommons.org/licenses/by/4.0/ http://bijps.uobaghdad.edu.iq/index.php/bijps.com http://creativecommons.org/licenses/by/4.0/