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Psoriasis in Sweden: observational studies from an epidemiological perspective
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Dermatology and Venerology.ORCID iD: 0000-0002-2610-5033
2016 (English)Doctoral thesis, comprehensive summary (Other academic)Alternative title
Psoriasis i Sverige : observationella studier ur ett epidemiologiskt perspektiv (Swedish)
Abstract [en]

Background: Psoriasis is a heterogeneous disease with several clinical manifestations; the symptoms are characterized by redness, scaliness and thickness of the skin. There are several treatment options available for psoriasis and patients with moderate to severe psoriasis generally need systemic agents. In 2004 biologics were introduced for patients with moderate to severe psoriasis in Sweden.

Methods: The Swedish Health Care Registers and the Swedish registry for systemic treatment of psoriasis PsoReg, were used to; estimate the incidence of psoriasis cases in the Swedish specialist care, to examine the treatment allocation and important factors related to the initiation of especially biologic treatment.

Results: On average 9000 new psoriasis patients entered specialist care in Sweden each year under study, corresponding to an incidence of 98 patients per 100,000 person-years. In the treatment allocation analysis of the incident psoriasis cases in the Swedish specialist care Patients living in a Metropolitan Area and with a University degree were more likely to initiate a biologic treatment. By analysing biologic-naïve patients enrolled in PsoReg, PASI (the physician’s assessment of the psoriasis severity) and Psoriasis Arthropathy were shown to be two important factors associated with the initiation of biologic treatment while sex was not. Furthermore, it was also shown that the decision to initiate biological treatment was more strongly associated with PASI than with DLQI (the patients’ assessment of the disease impact Quality of Life).

Conclusion: These studies indicate that there are inequalities in the assignments of systemic psoriasis treatments (especially in biologic treatment). Since the allocation of treatments should not depend on sex, education or residency in a Metropolitan Area but rather the need of care, it is important that future studies continue analysing possible factors that could influence the initiation of treatment in clinical practice.

Place, publisher, year, edition, pages
Umeå: Umeå Universitet , 2016. , 48 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1776
Keyword [en]
Psoriasis, Systemic treatments, Biologic treatments, PASI, DLQI, Register-based research
National Category
Dermatology and Venereal Diseases
Research subject
Dermatology and Venerology
Identifiers
URN: urn:nbn:se:umu:diva-113894ISBN: 978-91-7601-402-8 (print)OAI: oai:DiVA.org:umu-113894DiVA: diva2:891012
Public defence
2016-01-22, Sal E04, byggnad 6E, Norrlands Universitetsjukhus, Umeå, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2016-01-08 Created: 2016-01-05 Last updated: 2016-01-07Bibliographically approved
List of papers
1. Specialist treatment of psoriasis in Sweden between 2007 and 2009: Incidence and treatment allocation during a two-year follow-up
Open this publication in new window or tab >>Specialist treatment of psoriasis in Sweden between 2007 and 2009: Incidence and treatment allocation during a two-year follow-up
(English)Manuscript (preprint) (Other academic)
National Category
Dermatology and Venereal Diseases
Research subject
Dermatology and Venerology
Identifiers
urn:nbn:se:umu:diva-113899 (URN)
Available from: 2016-01-05 Created: 2016-01-05 Last updated: 2016-01-07
2. The higher proportion of men with psoriasis treated with biologics may be explained by more severe disease in men
Open this publication in new window or tab >>The higher proportion of men with psoriasis treated with biologics may be explained by more severe disease in men
2013 (English)In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 8, no 5, e63619- p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVES: Moderate to severe psoriasis, once regarded as merely a skin disease, is today seen as an inflammatory systemic disease. The sex ratio of the prevalence of psoriasis is balanced. In recent years several reports have documented that men receive more systemic or UV treatment than women, and different hypotheses were made. In PsoReg, the national registry for systemic treatment of psoriasis in Sweden, we have, like other European registries, observed a predominance of men (59%), especially of men treated with biologics (63%). Biologics are a relatively new group of very effective but high-priced drugs. The objective of this study was to analyse if women are discriminated by not having the same access to the high-priced biologics.

DESIGN: Population based cohort study using data from a nationwide quality register of psoriasis patients.

POPULATION: 2294 patients with moderate to severe psoriasis receiving systemic treatment from a specialist in dermatology.

MAIN OUTCOME MEASURES: Time to initiation of biologic treatment. A multiple Cox proportional hazard's regression was performed, with time to initiating a biologic treatment as the outcome in order to assess the independent role of the patient's sex in initiating such therapy. The psoriasis severity was defined as a time-varying variable.

RESULTS: Men had more severe psoriasis than women according to the Psoriasis Area and Severity Index (PASI), regardless of age at enrolment, and throughout the study period. The analysis in the multiple Cox regression show that age, psoriasis severity and psoriasis arthropathy were relevant factors for initiating biologic therapy, whereas sex is not.

CONCLUSIONS: Although as many women as men are believed to suffer from psoriasis, men seem to be more severely affected by psoriasis. The asymmetry in allocation of biologic therapy thereby probably reflects the differing disease activity between the sexes, and is not a discrimination against women per se.

Place, publisher, year, edition, pages
Public library of science, 2013
Keyword
system; index; area; risk
National Category
Dermatology and Venereal Diseases
Identifiers
urn:nbn:se:umu:diva-71355 (URN)10.1371/journal.pone.0063619 (DOI)000319052700054 ()23691076 (PubMedID)
Available from: 2013-05-27 Created: 2013-05-27 Last updated: 2017-12-06Bibliographically approved
3. Decision for biological treatment in real life is more strongly associated with the Psoriasis Area and Severity Index (PASI) than with the Dermatology Life Quality Index (DLQI)
Open this publication in new window or tab >>Decision for biological treatment in real life is more strongly associated with the Psoriasis Area and Severity Index (PASI) than with the Dermatology Life Quality Index (DLQI)
2015 (English)In: Journal of the European Academy of Dermatology and Venereology, ISSN 0926-9959, E-ISSN 1468-3083, Vol. 29, no 3, 452-456 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Following the establishment of the National Quality Registry for systemic psoriasis treatment (PsoReg), the two psoriasis outcome measurements, Psoriasis Area and Severity Index (PASI) and Dermatology Life Quality Index (DLQI), are now integrated in clinical practice in Sweden. According to current guidelines, the initiation of a biological treatment should depend on a combination of the physician's (PASI) and the patients' assessment of the disease impact on a health-related quality of life measure (DLQI).

OBJECTIVE: To evaluate if either of the two measures, PASI or DLQI, is more strongly associated with initiation of biological therapy.

METHODS: The study is based on 2216 patients suffering from moderate to severe psoriasis who were biological naïve at enrolment to PsoReg. The relationship between the two measures PASI and DLQI and initiation of biological treatment (as outcome) were estimated by a logistic regression and a Cox proportional hazard's model with combinations of PASI and DLQI as independent variables.

RESULTS: The adjusted regression models showed that patients with high PASI score and low DLQI score had a higher chance to receive biological treatment compared to patients with low PASI score and high DLQI score.

CONCLUSION: The decision to initiate biological treatment is more strongly associated with PASI than with DLQI. However, since the DLQI reflects both socio-economic costs and patient suffering better than PASI, the relevance of the DLQI may be underestimated in clinical practice.

Place, publisher, year, edition, pages
John Wiley & Sons, 2015
National Category
Dermatology and Venereal Diseases
Identifiers
urn:nbn:se:umu:diva-89800 (URN)10.1111/jdv.12576 (DOI)000350039500006 ()24911993 (PubMedID)
Available from: 2014-06-12 Created: 2014-06-12 Last updated: 2017-12-05Bibliographically approved
4. Severity of psoriasis differs between men and women: a registry based study of the clinical outcome measure Psoriasis Area and Severity Index (PASI) in 5438 patients
Open this publication in new window or tab >>Severity of psoriasis differs between men and women: a registry based study of the clinical outcome measure Psoriasis Area and Severity Index (PASI) in 5438 patients
2017 (English)In: American Journal of Clinical Dermatology, ISSN 1175-0561, E-ISSN 1179-1888, Vol. 18, 583-590 p.Article in journal (Refereed) Published
Abstract [en]

Background: Psoriasis is a common skin disease and moderate to severe psoriasis is associated with a dose-dependent risk for metabolic and cardiovascular morbidity. It has previously been speculated that women have less severe psoriasis, as men are overrepresented in psoriasis registers and consume more care.

Objective: The objective of this study was to investigate, for the first time, the sex differences in the severity of psoriasis using the gold standard of severity measurement, the Psoriasis Area and Severity Index (PASI), and the distinct elements of the PASI score.

Design, Setting and Participants: This was a cross-sectional study based on the national registry for systemic treatment of psoriasis in Sweden (PsoReg), with 5438 patients experiencing moderate to severe psoriasis. Differences in the PASI score and its elements at enrolment were tested by multivariable ordinal logistic regressions.

Main Outcome Measures: The different components of the PASI score were used to analyze the assessment of disease severity. For each body area (head, arms, trunk, and legs), the score of the plaque characteristics and degree of skin involvement were used as outcomes.

Results: Women had statistically significantly lower median PASI scores (5.4) than men (7.3) [p < 0.001], which was consistent across all ages. The difference remained statistically significant in a multivariable linear regression. The itemized PASI analyses from the Mann–Whitney–Wilcoxon tests and the adjusted ordinal logistic regressions confirmed that women had significantly lower scores than men in all areas of the body, except for the head. No differences in the use of medications prior to enrolment could be found that may cause this difference between the sexes.

Conclusions: As the PsoReg contains the detailed disease measurement PASI, which was traditionally used for selected participants in clinical studies only, a nationwide unselected population could be investigated. The fact that women have less severe psoriasis can explain the dominance of males in the systemic treatment of psoriasis. These findings motivate a gender perspective in the management of psoriasis and in the prevention and management of its comorbidities.

National Category
Dermatology and Venereal Diseases
Research subject
Dermatology and Venerology
Identifiers
urn:nbn:se:umu:diva-113900 (URN)10.1007/s40257-017-0274-0 (DOI)000405548600011 ()
Available from: 2016-01-05 Created: 2016-01-05 Last updated: 2017-08-21Bibliographically approved

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