2014.4-8.Unique

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Our Dermatol Online.  2014; 5(4): 364-367
DOI:.  10.7241/ourd.20144.92
Date of submission:  18.07.2014 / acceptance: 02.09.2014
Conflicts of interest: None
 

UNIQUE PSORIATIC LESION VERSUS MULTIPLE LESIONS

Anca Chiriac,1,2 Piotr Brzezinski3, Liliana Foia4, Anca E Chiriac4, Tudor Pinteala4, Caius Solovan5

1Apollonia University Iasi, Dermato-Physiology Department, Strada Muzicii nr 2, Iasi-700399, Romania
2Nicolina Medical Center, Department of Dermatology, Iasi, Romania
3Department of Dermatology, 6th Military Support Unit, os. Ledowo 1N, 76-270 Ustka, Poland
4Universityof Medicine and Pharmacy „Gr. T Popa” Iasi, Romania
5University of Medicine and Pharmacy „V Babes” Department of Dermatology, Timi¬soara, Romania
 

Corresponding author:  Prof. Anca Chiriac    e-mail: anca.chiriac@yahoo.com


 

Abstract
Aim: To evaluate the number of lesions of psoriasis and to find risk factors for multiple lesions.
Material and Methods: 1,236 patients (male 54.13%, female 45.87%) with psoriasis were seen over a period of 8 years in an Outpatient Clinic. Patients filled out questionnaires containing age at onset, number of lesions and location at the beginning of the disease, gender, type and localization of psoriasis at the time of clinical examination, psoriasis family history, previous treatment, comorbidities, and social status.
Results: The number of psoriasis lesions correlates with: onset age of psoriasis (F=8.902, p=0.0029); age at the moment of clinical examination (F=8.902, p=0.0029); residence in rural area (χ2=8.589, p=0.00338, 95%CI); alcohol intake (χ2=16.47, p=0.00005, 95%CI); smoking (χ2=8.408, p=0.00373, 95%CI); occupation: workers/pupils/students (χ2=14.11, p=0.0069, 95%CI).
Conclusions: There is a correlation between number of psoriatic lesions and some factors. Multiple lesions were observed in older patients, smokers and drinkers, coming from rural area and social active (workers and pupils/students). No correlation was statistically proved between number of lesions and gender, comorbidities and family history of psoriasis..
 
Key words:  psoriasis; number of lesions; Romania; statistical analysis; statistical correlation; large clinic-based sample

 

Aim
The aim of the work was a evaluate the number of lesions of psoriasis and to find risk factors for multiple lesions.
 
Material and Methods
At the end of 2011, we initiated a project which intended to evaluate the number of lesions of psoriasis at the moment of clinical examination and to find correlations between clinical characteristics of lesions and other factors: onset age, present age, gender, residence, smoking, alcohol intake, severity index, comorbidities, work status, family history of psoriasis. 1,236 patients (male 54.13%, female 45.87%) with psoriasis were seen over a period of 8 years in an Outpatient Clinic in Romania, by the same dermatologist, the diagnosis was certified by clinical features and, when necessary, by skin biopsies. The subjects were also asked about other medical problems, the presence of similar lesions among other members of the family.
 
Results
The distribution of psoriasis was clearly recorded. Active lesions were noted on the scalp, face, trunk, anogenital area, arms, legs, hands, feet or nails, i.e. in 10 different locations (Tabl I).
 


Nr of cases
%
Nail psoriasis
165
13.35%
Psoriatic arthritis
309
25.00%
Koebner
173
14.00%
Scalp psoriasis
681
55.10%
Gutate psoriasis
146
11.81%
Superior limbs
788
63.75%
Inferior limbs
736
59.55%
Trunk
462
37.38%
Face
55
4.45%
Palmo-plantar
205
16.59%
Others
206
21.44%
Total
1236

               Table I. Clinical aspect of psoriasis.  

 
The most common finding was s psoriasis on the arms and legs, followed by scalp psoriasis. Less common locations were the trunk and palmo-plantarregion. The facial area was affected in 4.45% of all the examined persons. Majority of patients (82.85%) had multiple skin lesions at the moment of clinical inspection. Of 1236 patients enrolled in the study an approximately equal distribution was observed among patients with solitary lesion or 2, 3 or 4 body areas involved (Tabl. II).
 

Location
Nr. cases
%
Unique lesions
212
17.15%
Multiple lesions
1024
82.85%
2 body areas
266
21.55%
3 body areas
244
19.74%
4 body areas
240
19.41%
5 body areas
155
12.54%
6 body areas
76
6.15%
7 body areas
30
2.43%
8 body areas
12
0.97%
10 body areas
1
0.08%
Total 1236  

               Table II. Evaluating the number of psoriatic lesions at the moment of clinical examination.

 
More generalized forms were very rare. A few patients (1.21%) with multiple onset lesions turned to have later unique lesions; 7.61% of them preserved the initial multiple lesions (Tabl. III).
 

Onset location
Location at the moment of examination
Location at the moment of examination
%

unique location
multiple location

unique location -onset
197 / 15.94%
930 / 75.24%
1127
multiple location -onset
15 / 1.21%
94 / 7.61%
109
Total
212
1024
1236

               Table III. Comparison between unique onset lesion ad multiple lesions at the moment of clinical examination.

 
A small percentage (15.94%) of onset single lesion patients in time remained with unique (the same or different) cutaneous psoriasis stigma. Vast majority of cases (75.24%) with declared unique psoriatic lesion at the onset of the disease developed multiple skin manifestations over short or long period of time. Statistical report shows no marked relationship between locations of the lesions at the first diagnosis of psoriasis and at the moment of onset evaluation. (r= 0.1406, χ2=1.018, p=0.312, 95%CI). Evaluation of risk factors associated with multiple psoriatic lesions was done and the results are sumarrized in Table IV. Table V presented PASI vs number of lesions.
 

Location

unique lesionnr patients / %
multiple lesionsnr patients / %
Urban residence
192 / 18.53%
844 / 81.47%
Rural residence
20 / 10.00%
180 / 90.00%
Male gender
103 / 15.40%
566 / 84.60%
Female gender
109 / 19.22%
458 / 84.60%
Mild psoriasis
132 / 24.63%
404 / 75.37%
Moderate psoriasis
65 / 13.00%
435 / 87.00%
Severe psoriasis
15 / 7.50%
185 / 92.50%
Comorbidities absent
135 / 18.44%
597 / 81.56%
Comorbidities present
77 / 15.28%
427 / 84.72%
Alcohol consumer
45 / 10.98%
365 / 89.02%
Non acohol consumer
167 / 20.22%
659 / 79.78%
Nonsmoker
171 / 19.06%
726 / 80.94%
Smoker
41 / 12.09%
298 / 87.91%
Pupil/student
45 / 3.64%
137 / 11.08%
Worker
130 / 10.52%
622 / 50.32%
Retired
20 / 1.62%
129 / 10.44%
Social assisted
1 / 0.08%
27 / 2.18%
Job less
16 / 1,29%
109 / 8.82%
Family history absent
150 / 17.22%
721 / 82.78%
First degree relatives with psoriasis
38 / 19.00%
162 / 81.00%
Second degree relatives with psoriasis
15 / 13.04%
100 / 86.96%
Third degree relatives with psoriasis
7 / 19.44%
29 / 80.56%
Fourth degree relatives with psoriasis
2 / 14.29%
12 / 85.71%

               Table IV. Number of lesions vs residence, gender, index severity, presence of comorbidities, alcohol, smoking, work
               status, family history of psoriasis.

 

Parameter/factor
PASI index-correlation
Number of psoriatic lesions-correlation
Onset age
yes
no
Age at the moment of clinical examination
yes
yes
Gender (male)
yes
no
Residence in rural area
yes
yes
History family of psoriasis
yes
no
Presence of comorbidities
yes
no
Alcohol and smoking
yes
yes
Work status-education
Retired persons-jobless
Workers/pupils-students

               Table V. PASI vs number of lesions.

 
1. Onset age vs number of lesions
Median onset age of psoriasis does not show significant differencies related to location of the psoriatic lesions: unique vs multiple. (F=12.93, p=0.000337, 95%CI)
 
2. Age at the moment of clinical examination vs. number of lesions
The median age of patients with multiple lesions (45.55years±15.72SD) was significant higher (F=8.902, p=0.0029) than the same parameter calculated for patients with unique lesion (41.99years±15.72SD).
 
3. Residence vs. number of lesions
The risk for multiple lesions is 2.05 higher in rural area. A moderate association is evidenced between residence and multiple location (χ2=8.589, p=0.00338, 95%CI)
 
4. Gender vs. number of lesions
There is no association between gender of psoriasis patients and number of the lesions (χ2=3.164, p=0.0752, 95%CI)
 
5. Psoriasis severity index and number of lesions
It is obvious that a very strong correlation is proved (and attest our study) between the severity of the disease and number of psorasis lesions (r=0.414, p<<0.01, 95%CI).
 
6. The presence of comorbidities vs. number of lesions
There is no correlation between the presence of comorbidities and multiple locations (χ2=2.103, p=0.146, 95%CI). Patients with psoriasis and comorbidities have a very low risk of developing multiple skin lesions. (OR=1.25).
 
7. Alcohol intake(by declaration) vs. number of lesions
A strong association is confirmed among alcohol intake and multiple location (χ2=16.47, p=0.00005, 95%CI). The risk for disseminated psoriasis lesions in alcohol consumers is 2.06 higher compared to non-drinkers (OR=2.06).
 
8. Smoking vs number of lesions
Smoking and multiple location are correlated (χ2=8.408, p=0.00373, 95%CI). Risk found in smokers to multiple lesions is 1.71 higher compared to non-smokers. (OR=2.06).
 
9. Occupation vs number of lesions
Multiple lesions of psoriasis were noted in workers (50.32%) and pupils/students (11.08%) Only 2.18% of people, those with no income had multiple lesions. A strong association links the occupation and location of lesions (χ2=14.11, p=0.0069, 95%CI).
 
10. Family history of psoriasis vs number of lesions
Statistically there is no correlation between the presence of family history of psoriasis and number of lesions. (r= 0.0017, χ2=2.06, p=0.724, 95%CI).
 
Discussion
We have used a simple and direct method of recording any active psoriasis lesion in ten different body regions, instead of using the PASI score or DLQI appreciations. The extent of the skin disease at the moment of present examination showed no correlations with: age at the moment of examination, confirming different other studies that have reported no difference in extent of lesions linked to the age at onset [1,2]. Multiple lesions were described in late psoriasis (over 40 years of age), although reports support the hypothesis that late psoriasis is milder than early psoriasis [3] based on PASI evaluation. It is well accepted that psoriasis predominates in men and mild to severe forms of the disease have been reported in male patients [4]. Present study does not attest any link between gender of the patients enrolled in the study and number of psoriasis lesions. Alcohol and smoking are two parameters strongly connected to extent of psoriasis due to different causes: stress activity, limited access to dermatological care, poor hygiene status, associated diseases induced by alcohol and smoking, lack of stable income and deprived nutrition. Although it is well known that severe forms of psoriasis (PASI 10 or higher) are associated with the presence of co-morbidities, present study does show any correlation between the extent of psoriatic lesions and the occurrence of other systemic diseases [5]. In urban areas it is described a higher prevalence, but with mild forms, of psoriasis, while in rural areas severe and untreated forms are commonly seen. Explanations can be found in reduced address ability of people living in villages to a specialized psoriasis center, late diagnosis and long period of time with no treatment, longer exposure to sun due to open air activities, smoking and alcohol intake, different nutrition habits, diminished skin care hygiene measures. These may also clarify the prevalence of patients with multiple lesions of psoriasis in patients living in rural areas. Work status and education are two major factors taken into account when evaluating a patient with psoriasis: severity index correlates with both; multiple lesions of psoriasis were seen in workers and pupils/students while persons with low income and poor living conditions had no extensive diseases. Family history of psoriasis, although admitted to explain at least partially the severity of the disease in adults, does not have any impact on number of lesions, accordingly to our study.
 
Conclusion
The number of psoriasis lesions correlates with:
– age at the moment of clinical examination (F=8.902, p=0.0029);
– residence in rural area (χ2=8.589, p=0.00338, 95%CI);
– alcohol intake (χ2=16.47, p=0.00005, 95%CI);
– smoking (χ2=8.408, p=0.00373, 95%CI);
– occupation:workers/pupils/students (χ2=14.11, p=0.0069, 95%CI).
 
REFERENCES
1. Ikäheimo I, Tiilikainen A, Karvonen J, Silvennoinen-Kassinen S. HLA risk haplotype Cw6, DR7, DQA1*0201 and HLA-Cw6 with reference to the clinical picture of psoriasis vulgaris. Arch Dermatol Res. 1996;288:363-5.
2. Inerot A, Enerbäck C, Enlund F, Martinsson T, Samuelsson L, Wahlström J, et al. Collecting a set of psoriasis family material through a patient organisation; clinical characterisation and presence of additional disorders. BMC Dermatol. 2005;5:10.
3. Henseler T, Christophers E. Psoriasis of early and late onset: characterization of two types of psoriasis vulgaris. J Am Acad Dermatol. 1985;13:450–6.
4. Hägg D, Eriksson M, Sundström A, Schmitt-Egenolf M. The higher proportion of men with psoriasis treated with biologics may be explained by more severe disease in men. PLoS One. 2013;8:e63619.
5. Altobelli E, Petrocelli R, Maccarone M, Altomare G, Argenziano G, Giannetti A, et al. Risk factors of hypertension, diabetes and obesity in Italian psoriasis patients: a survey on socio-demographic characteristics, smoking habits and alcohol consumption. Eur J Dermatol. 2009;19:252-6.


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