Pattern of psoriasis in the Hail region of Saudi Arabia

Psoriasis is a chronic immune-mediated inflammatory disorder affecting the skin, nails, and joints in both children and adults. It is non-infectious disease that affects people of all ages, with no predilection for gender [13]. It can involve the skin, nails, and joints and is associated with a number of comorbidities. It can have a significant negative impact on the physical, emotional, and, psychosocial wellbeing of affected patients. The etiology remains unclear and treatment is still mostly based on combating acute symptoms. Although psoriasis occurs worldwide, its prevalence varies considerably. In the United States, approximately 2% of the population are affected.

Psoriasis is estimated to affect 2–4% of the population of the western world [15]. The rate of psoriasis varies 17according to age, region, and ethnicity; a combination of environmental and genetic factors is thought to be responsible for these differences [15]. It can occur at any age, although it most commonly appears for the first time between the ages of 15 and 25 years. Approximately one-third of people with psoriasis report being diagnosed before age 20 [16].

As regards treatment, in the United Kingdom, a population-based study reported that 91.8% of patients with a diagnostic code for psoriasis received a prescription for therapy; topical corticosteroids were the most frequently prescribed medication, received by 61.4% of patients. The next most commonly used prescription treatment types were corticosteroid combination products (40.4% of patients), topical vitamin D analogs (39%), topical tar (24.5%) and systemic agents (2.3%) [17,24].

In our study carried out in 2019, the data were collected from a sample of patients in our dermatology clinic. At that time, not all new biological treatments were available in our clinic. Psoriasis appears to be slightly more prevalent among men than women (57.4% in our study).

Psoriasis is a disease that has the Koebner phenomenon. As work causes more trauma to the body, workers (53.7%) are more susceptible than non-workers. Psoriasis can be aggravated by physical stress (72% of cases in our study). It can also increase with smoking; however, non-smokers were more affected in our study (69%), maybe because of the stigma of disclosing this information to our questioner. Psoriasis is not a hereditary or genetic disease and our study showed that consanguinity is low between psoriasis patients (39%). Plaque psoriasis is the most common type of psoriasis (42% in our study) and the most common location is extremities, especially in elbows and knees (57%).

There are different types of psoriasis. In a population-based retrospective study carried out among 3,105 subjects, the prevalence of psoriasis was 52.6%. The majority of subjects (79%) had chronic plaque psoriasis, followed by scalp psoriasis (42%), guttate psoriasis (8%), sebo-psoriasis (5.3%), and pustular psoriasis (3.3%) [17]. Another population-based study conducted among patients aged under 18 years reported that chronic plaque psoriasis was the most common type (73.7%) [18]. An epidemiologic survey of 112 childhood psoriasis cases reported that the most common form of psoriasis was plaque (69.6%), followed by guttate (25.9%) [19]. In China, a retrospective epidemiologic study of 277 psoriasis patients found that 190 (68.6%) had plaque‐type psoriasis, 80 (28.9%) guttate psoriasis, three (1.1%) pustular forms of psoriasis, and four (1.4%) erythroderma [20].

In the United States, a large prospective study conducted among participants from three cohorts, namely, the Health Professionals Follow-up Study (HPFS), the Nurses’ Health Study (NHS) and the Nurses’ Health Study 2 (NHS II), described the prevalence of psoriasis phenotypes as follows: plaque 55%, scalp 52%, palmar–plantar 14%, nail 23%, and inverse 21% in the NHS (n = 1604); plaque 60%, scalp 56%, palmar–plantar 16%, nail 27%, and inverse 24% in the NHS II (n = 1575); and plaque 55%, scalp 45%, palmar–plantar 12%, nail 27%, and inverse 30% in the HPFS (n = 646) [21].

Bedi [23] analyzed data on 530 psoriasis patients, finding that chronic plaque-type psoriasis was the most common (90%) clinical phenotype, followed by palmoplantar psoriasis and flexural psoriasis; by contrast guttate psoriasis, mucosal involvement, and psoriatic erythroderma were uncommon. In northern India, a study of 419 patients reported that classical plaque psoriasis was the most frequent clinical presentation [254 (60.6%) patients], followed by plantar psoriasis [54 (12.8%)]. Nail involvement was observed in 130 (31%) cases [26].

The most commonly involved sites were extremities (59.9%) and the scalp (46.8%) [18]. In another study in China, cases were divided into an initial onset and recurrent group; the top three sites in the initial onset group were the extensors of legs (65.5%), arms (51.4%), and scalp (46.5%); the same was found in the recurrent group [20]. Okhandiar et al. [22] collected epidemiological data on 116 psoriasis patients from various medical colleges and found that the extensors (93%) were the most common site of involvement followed by the scalp (88%); the face, palms, soles, and nails were affected in one-third of cases. Kaur et al. [24] reported the scalp (25%) as the most common first site of involvement followed by the legs (20.6%) and arms (11.7%); oral (0.7%) and genital (0.4%) mucosal involvement was found to be uncommon.

As regard complications, Okhandiar et al. found pruritus to be present in 95% of cases, while a burning and smarting sensation arose in around 15% of cases [22]. Bedi noted itching to be a significant complaint in 81% of patients [23]. Kaur et al. found that burning and stiffness were uncommon (1%), while pruritus was complained about by 65% of patients [24].

Our government provides free therapy for all citizens for any diseases and our patients are almost fully compliant to their medication regimens, with 94%. 64% reaching the PASI 75% score (Figure 2). Most of our patients take the biological treatment because our clinic is the only one in the Hail region providing it; our clinic is also a referral center for difficult dermatological diseases in the Hail area. In general, most medication is written in English and few patients know the name of their medication, as shown in our study (only 37% knew their medication).

The new evolution of biological treatment makes choosing treatment difficult; however, our clinic has only three biological treatments. The first is etanercept, which later came with an injectable pen. Most of our patients use etanercept (58%) (Figure 1). The biological treatments have very good improvement rates. As our study shows, most patients (52%) reach the PASI 75 score (Figure 3).