Severity of Psoriasis Among Adult Males is Associated with Smoking, Not with Alcohol Use.

Sir,

I read with great interest this engaging and insightful study, the first of its kind from India, investigating the relationship between psoriatic severity in males, and its relationship with smoking and alcohol use.[1] I wish to gain further clarity and comment on several issues.

There is little mention of the distribution of psoriasis area and severity index (PASI) scores in the studied cohort. By arbitrarily categorizing the top quartile (n = 84) of the subject group who possessed the highest PASI scores as having the “more-severe” psoriasis may only be useful in a frequency distribution of normally distributed PASI values. If PASI values were skewed to the left, subjects with high PASI scores (up to and including a score of 13.88) would still inadvertently be considered as suffering from low-severity psoriasis. This may potentially affect all data analysis when comparing the “more-severe” with the “less-severe” group.

The study does not take into account the subgroup of subjects who meet the criteria for both smoking and drinking-it may be interesting to evaluate the possible interaction between these two variables in lieu of them both being possible confounding factors.

The Fagerstrom score assesses Nicotine dependence and its impact on daily living. However, Nicotine dependence may or may not directly correlate with actual smoking intensity. Subjects who were ex-smokers but had given up smoking more than a year ago were deemed to be non-smokers, this despite the possibility of these subjects possessing an extensive number of pack years from smoking in the past nonetheless. It may be interesting to evaluate the relationship between the number of pack years of a patient and psoriatic severity-in lieu of the benefits of smoking cessation, and whether effects on psoriatic severity is accumulative over the years of smoking.

Thank you for your consideration.