Management practice, quality of life and associated factors in psoriasis patients attending a dermatological center in Ethiopia.

BACKGROUND: Psoriasis is a chronic inflammatory disease characterized by keratinocyte hyperproliferation and aberrant differentiation with great negative impact on patients' quality of life (QoL). This study aimed at assessing factors influencing management practice, and QoL and its associated factors among ambulatory psoriatic patients visiting All Africa Leprosy, Tuberculosis and Rehabilitation Training (ALERT) Center in Addis Ababa, Ethiopia.
MATERIALS AND METHODS: A cross sectional study was conducted in 207 patients with psoriasis attending the dermatology clinic of ALERT Center in Addis Ababa, Ethiopia. Data were collected using structured questionnaire and patients' chart review. Dermatology Life Quality Index (DLQI) was used to measure patients' QoL. Patients' characteristics were summarized using descriptive statistics and predictors of QoL were identified by binary logistic regression.
RESULTS: Among 207 study participants, 122 (58.9%) were females. The mean age of the study population was 37.92 (SD = 14.86) years (ranging from 16 to 68 years). The mean age at which diagnosis of psoriasis made was 32 (SD = 13.7) years ranging from 10 to 62 years. The duration of the disease in 112 (54.1%) patients were more than or equal to 5 years. Majority of study participants 145 (70.0%) had plaque psoriasis followed by sebopsoriasis, 24 (11.6%). The majority of plaque psoriasis (80%) cases were managed by topical corticosteroids with or without salicylic acid or coal tar and only 21 (14.5%) treated by methotrexate alone. The mean DLQI was 6.25 corresponding to a moderate effect. Symptoms and feelings were the most affected domains of QoL. Factors associated with poor QoL were female [AOR = 0.17 (95%CI: 0.06, 0.48)], low, above average and high family income ([AOR = 0.12 (95% CI: 0.02, 0.56)], [AOR = 0.06 (95% CI:0.01, 0.32)], and [AOR = 0.03 (95% CI: 0.01, 0.22)]), respectively, and primary education level [AOR = 0.14 (95% CI: 0.03, 0.64)] while being on systemic therapy [AOR = 4.26 (CI: 1.18, 15.35)] was predictor of better QoL. Poor QoL was predominant in females [AOR = 0.17 (95%CI: 0.06, 0.48)], low income [AOR = 0.12 (95% CI: 0.02, 0.56] patients, and patients with primary education level [AOR = 0.14 (95% CI: 0.03, 0.64)]. Patients on systemic therapy [AOR = 4.26 (CI: 1.18, 15.35)] had good QoL.
CONCLUSION: Our study identified that topical corticosteroids were the mainstay of psoriasis treatment in the dermatology clinic of ALERT Center in Addis Ababa, Ethiopia. Moderate effect QoL was achieved by study participants based on DLQL score.

Introduction

Psoriasis is a chronic inflammatory disease affecting skin and joints characterized by erythematous papules and plaques [1]. It is also associated with an array of significant medical and psychiatric comorbidities, including psoriatic arthritis, cardiovascular disease, diabetes, malignancy, depression, and anxiety [2, 3]. Thus, psoriasis requires a timely management otherwise it is subjected to flares and remissions that come in many different variations and degrees of severity which may be symptomatic throughout life and may be progressive with age or wax and wane in its severity [4].

Based on morphologic characteristics, several subtypes of psoriasis have been identified which is necessary to guide appropriate management. However, clinical findings often fit into more than one category. The most common subtypes are plaque, guttate, erythrodermic, pustular, and inverse psoriasis [5, 6]. Psoriasis affects about 2%–3% of the world’s population although its prevalence varies among different ethnicities and geographic locations [7]. Higher altitudes are associated with the largest prevalence. Northern Europe and East Asia have the highest and lowest prevalence rates, respectively. Similarly, global reports on psoriasis showed a wide range of prevalence varying from 0.09% to 11.4% [7, 8]. In Africa, epidemiology of psoriasis is not well described. However, the prevalence rates vary from 1.9% to 2.5%, and 0.025% to 0.9% were reported in Eastern and Western Africa countries, respectively [9].

Psoriasis has a negative impact on the psychological status, social interaction, and overall QoL of the patients [10, 11]. Studies showed that psoriasis affects day-to-day activities, occupational, and sexual functioning, often independent of the extent, and severity of skin lesions [11-13]. It was also demonstrated that it can cause anxiety, depression, anger, and embarrassment, which then leads to social isolation and absenteeism at work and school. Social and sporting activities can become difficult since they worry about what other people think of their appearance [14]. It has also great economic and financial consequences [15].

The treatment of psoriasis comprises topical agents, phototherapy, systemic immunosuppressants, and, more recently, biologics [16]. Topical agents are widely used for localized and milder forms of these diseases and to control flares of skin disease in patients with widespread or more severe one. On the other hand, systemic immunosuppressants and biologics are reserved for more severe disease because of side effects associated with chronic use. However, a number of immunobiologics with high efficacy and reduced side effect have recently been introduced [17].

There are unmet needs regarding the management of psoriasis in Africa. A stepwise approach, based on disease severity, is recommended in many African regions for psoriasis management. When systemic therapy is indicated, methotrexate, cyclosporin A and acitretin are first-line options in Africa countries [18]. Poor multidisciplinary approach, logistic problem of running clinic within outpatient setting, cost of medications, lack of patients understanding of their disease and, poor adherence to medications, limited availability of interested dermatologists and specialist and specialist nurses are limiting factors to provide comprehensive care for psoriatic patients in Africa and other similar developing countries [18]. In Ethiopia, topical agents (steroids, salicylic acid and coal tar), methotrexate, other systemic immunosuppressants and sun are the conventional treatments for psoriasis [9].

There is no generally accepted consensus to declare the treatment of psoriasis is successful or not, however, patient care should include the provision of effective, convenient, and safe drugs, patient-reported outcomes like treatment preference, satisfaction, and QoL [19]. In Ethiopia, very little is known about the level of QoL and its determinants in psoriatic patients. Therefore, this study aimed to evaluate management practice, QoL and its associated factors among ambulatory psoriatic patients attending ALERT Hospital.

Materials and methods

Study setting

The study was conducted in the dermatology clinic of All Africa Leprosy, Tuberculosis and Rehabilitation Training Center (ALERT), located in Addis Ababa, Ethiopia. ALERT Center is one of the leading specialized hospitals in dermatology, ophthalmology, and plastic and reconstructive surgery in the country.

Study design and period

Hospital-based cross-sectional study design that involved interviewing patients and retrospective reviewing their charts was used in this study. Patients’ interview and data extraction were conducted from July 01, 2019 to December 31, 2019 and December 31, 2018 to December 31, 2019, respectively.

Eligibility criteria

Inclusion criteria

Patients included in this study were all patients with psoriasis and visiting dermatologic clinic during the study period, and patients with age ≥16 years that were on active follow-up and receiving treatment for at least 6 months.

Exclusion criteria

Patients who were physically ill, did not answer at least two questions in DLQI questionnaires, and unable to speak Amharic or didn’t have a caregiver to facilitate communication were excluded from the study. Moreover, incomplete patients’ medical charts were not included in the analysis.

Sample size and sampling technique

The sample size was computed based on a single population proportion formula. Since there was no previous study conducted on the QoL among psoriasis in Ethiopia, the proportion was taken as 50% and accordingly sample size was calculated to be 384. However, 504 patients (<10,000) visited the clinic during the study period and thus the finite population correction formula is used to calculate the actual sample size which was 218. Taking a 10% contingency (non-response rate), the final sample became 240 in our study. A systematic random sampling method was used to recruit samples for the study on each day of the data collection process. Sampling interval (kth) was determined by dividing the total number of psoriatic patients that came within the study period by estimated sample size (kth = 504/240 = 2). Thus, the first patient was selected randomly then every other patient was interviewed following physicians visit until the required sample was reached. In this study, 207 study participants were included in the final analysis after excluding patients with incomplete data.

Study variables

Dependent variables were management practice and QoL while independent variables were age, sex, educational status, marital status, occupation, monthly income, social drug habits, comorbidity, type of psoriasis, treatment modality, duration of psoriasis treatment, type and number of drugs.

Data collection tool

Data were collected using a structured data abstraction tool through interviewing patients and reviewing their medical records. The first part of the tool comprised socio-demographic characters (age, sex, educational status, monthly income, occupation, alcohol intake, chat chewing, and smoking status). The second part was the DLQI questionnaire, which was used to measure QoL. The final section comprised a tool to collect relevant clinical data like types of psoriasis, age at initial diagnosis, duration of disease, current medications, and comorbidities. The first part was translated into Amharic language and the Amharic version was administered to study participants.

The DLQI questionnaire was the first dermatology-specific QoL questionnaire. It consists of questions concerning patients’ perception of the impact of skin diseases on different aspects of their health-related quality of life over the last week. It was widely used in clinical studies of more than 80 countries and translated into more than 110 languages including Amharic [20]. DLQI is a 10-item questionnaire where question 1 and 2 assess symptoms and feelings; 3 and 4 assess daily activities; 5 and 6, leisure; 7, work or school; 8 and 9, personal relationships; and 10, treatment. DLQI is a 10-item questionnaire assessing patient’s symptoms and feelings, daily and leisure activities, work or school status, personal relationships and treatment.

The DLQI was rated on a 4-point scale with corresponding values of 3 = very much, 2 = a lot, 1 = a little and 0 = not at all; 0 = not relevant for each item. The highest sum is 30, and the lowest 0, and interpretation is: 0 to1 score = no effect (normal DLQL); 2 to 5 = small effect; 6 to 10 = moderate effect; 11 to 20 = large effect and 21 to 30 = extremely serious effect on patient’s life. DLQI scores > 5 were considered moderate-severely affected the QoL indicating poor QoL and scores ≤ 5 were considered the less affected QoL signifying a better QoL [21].

Data collectors and quality assurance

Data were collected by two nurses working in the outpatient dermatologic clinic under the supervision of the principal investigator. One-day training was given for data collectors on the study’s purpose, how to conduct a patient interview, and collect data from the patients’ charts. A pretest was done on twenty patients before actual data collection to check uniformity and understandability of the data collection tool and necessary modifications were made to the data collection tool. The principal investigator closely supervised the data collection process and was giving feedback and correction daily to maintain the quality of data.

Data analysis

After cleaning incomplete data, collected data was entered and analyzed using Statistical Package for Social Sciences (SPSS) version 25. Descriptive statistics were used for analyses of socio-demographic variables and relevant clinical data. Categorical variables were described by frequencies and percentages, and continuous variables were expressed by means and standard deviations. Binary logistic regression analysis was used to identify the determinants of QoL. Variables with p<0.25 in univariate analysis were further analyzed by multiple logistic regressions to avoid confounders. A p-value < 0.05 was used to confirm an association.

Ethical considerations

Ethical approval was received from the Ethical Review Board of the School of Pharmacy, College of Health Sciences, Addis Ababa University (Ref No: ERB/SOP/103/06/2019), and then permission was also obtained from ALERT Hospital, Department of Dermatology. In addition, informed written consent was obtained from the study participants and confidentiality was maintained by omitting patient identifiers and giving code number.

Results

Demographic characteristics of patients

A total number of 207 participants were included for the final analysis. 122 (58.9%) were females. The mean age of the study population was 37.92 (SD = 14.86) years (Table 1).

Table 1

Socio-demographic characteristics of psoriasis patients attending dermatology clinic of ALERT Center, Addis Ababa, Ethiopia (N = 207).

Socio-demographic	Category	Number (%)
Sex	Male	85 (41.1)
	Female	122 (58.9)
Age (in years)	16–35	106 (51.2)
	36–60	75 (36.2)
	>60	26 (12.6)
Marital status	Single	61 (29.5)
	Married	124 (59.9)
	Divorced	6 (2.9)
	Widowed	16 (7.7)
Educational status	Unable to read and write	39 (18.8)
	Primary school (Grade 1–8)	46 (22.2)
	Secondary school (Grade 9–12)	44 (21.3)
	Higher education (Diploma and above)	78 (37.7)
Occupation	Farmer	24 (11.6)
	Merchant/self-employed	46 (22.2)
	Employee	53 (25.6)
	Unemployed	14 (6.8)
	Housewife	22 (10.6)
	Student	29 (14.0)
	Daily laborer	10 (4.8)
	Others*	9 (4.3)
Monthly family income (ETB)**	Very low (≤860)	32 (15.5)
	Low (861–1500)	42 (20.3)
	Average (1501–3000)	24 (11.6)
	Above average (3001–5000)	32 (15.5)
	High (≥5001)	77 (37.2)
Social drug habits	Active cigarette smoker	3 (1.4)
	Regular alcohol user	7 (3.4)
	Regular chat chewer	11 (5.3)

ETB- Ethiopian birr

*retired, broker, guard

** based on Ethiopian civil service monthly salary scale for civil servants.

In this study, 124 (59.9%) were married participants and 78 (37.7%) participants had higher education (diploma and above). Of the total patients, 53 (25.6%) were employees, 46 (22.2%) were merchants/self-employed, and 77 (37.2%) patients had a high monthly family income.

Clinical characteristics of patients

As shown in Table 2, the mean age at which the diagnosis of psoriasis made was 32.0 (SD = 13.7) years. The duration of the disease in 112 (54.1%) patients were more than or equal to 5 years.

Table 2

Clinical characteristics of psoriasis patient attending dermatology clinic of ALERT Center, Addis Ababa, Ethiopia (N = 207).

Factors	Category	N (%)	Mean± SD	Range
BMI (Kg/m2)	≤18.5	15 (7.2)
	18.5–24.9	158 (76.3)
	25.0–29.9	17 (8.2)
Age at initial diagnosis (in years)	Early onset (<40)	144 (69.6)	32.0±13.7	10.0–62.0
	Late-onset (≥40)	63 (30.4)
Duration of the disease (in years)	<5	95 (45.9)	5.6±3.6	0.8–18.7
	≥ 5	112 (54.1)
Types of psoriasis	Plaque psoriasis	145 (70.0)
	Sebopsoriasis	24 (11.6)
	Scalp psoriasis	22 (10.6)
	Palmoplantar psoriasis	13 (6.3)
	Pustular psoriasis	2 (1.0)
	Inverse and nail psoriasis	1 (0.5)
Comorbid diseases	Yes	6 (2.9)
	No	201 (97.1)
Specific comorbidity presented	HIV	3 (1.4)
	Hypertension	2 (1.0)
	Diabetes mellitus and hypertension	1 (0.5)
Treatment modality	Topical corticosteroids	174 (84.1)
	Systemic agent	22 (10.6)
	Topical corticosteroids and systemic agents	11 (5.3)

Plaque psoriasis was the major clinical characteristics manifested in 145 (70.0%) patients and followed by sebopsoriasis manifestations 24 (11.6%). In the present study, 158 (76.3%) patients were in the normal body mass index (BMI) range and only 6 (2.9%) patients had comorbid diseases among which human immunodeficiency virus (HIV) and hypertension accounted for 1.4% and 1.0%, respectively.

Anti-psoriatic drug utilization practice

In our study, 185 (89.4%) of patients received topical corticosteroids for the treatment of psoriasis, and 12 (6.5%) patients have been prescribed two topical steroids with different potency. Methotrexate was prescribed for 33 (15.9%) patients. The average number of antipsoriatic drugs prescribed per patient was 1.8 (SD = 0.7). Plaque psoriasis was mostly managed by topical therapy alone, topical corticosteroids with or without salicylic acid/coal tar, 113 (77.9%) but only 21 (14.5%) treated by methotrexate alone. All patients with palmoplantar, sebopsoriasis, scalp, and pustular psoriasis were treated only by topical corticosteroids with or without salicylic acid (Table 3).

Table 3

Anti-psoriatic drugs utilization pattern among psoriasis patients attending ALERT Center, Addis Ababa, Ethiopia (N = 207).

Treatments	Types of Psoriasis, N (%)						Total
	Plaque	Inverse and nail	Palmoplantar	Sebopsoriasis	Scalp	Pustular
	N = 145	N = 1	N = 11	N = 26	N = 22	N = 2	N (%)
Topical corticosteroids							185 (89.4)
Betamethasone dipropoinate	106 (73.1)	0 (0)	2 (18.2)	22 (84.6)	20 (90.9)	2 (100)	150 (81.1)
Clobetasone propionate	5 (3.4)	0 (0)	6 (54.5)	0 (0)	0 (0)	0 (0)	12 (6.5)
Mometasone furoate	11 (7.6)	0 (0)	2 (18.2)	4 (16.7)	0 (0)	0 (0)	17 (9.2)
Clocortolone pivolate	8 (5.5)	0 (0)	3 (27.3)	0 (0)	2 (9.1)	0 (0)	12 (6.5)
Other topical agents
Salicylic acid	86 (59.3)	0 (0)	7 (63.6)	16 (66.7)	6 (27.3)	0 (0)	115 (55.6)
Coal tar	8 (5.5)	0 (0)	0 (0)	0 (0)	0 (0)	0 (0)	8 (3.9)
Systemic agents (traditional)
Methotrexate	32 (22.1)	1 (100)	0 (0)	0 (0)	0 (0)	0 (0)	33 (16.0)
Mean ± SD
No. of drugs	1.8±0.7	1.0±0.0	2.0±0.7	2.5± 0.7	1.4±0.5	1.0±0.0	1.8±0.7
No. of preparation	1.2±0.4	1.0±0.0	1.2±0.4	1.7±0.5	1.1±0.3	1.0±0.0	1.2±0.4

Quality of life domains

According to DLQI, 104 (50.2%) patients experienced a small effect and only 4 (2.0%) patients had an extremely large effect on the QoL (Fig 1).

Fig 1

Proportion of overall effect of psoriatic on QoL among psoriasis patients attending ALERT Hospital, Addis Ababa, Ethiopia (N = 207).

DLQI domains were affected differently among psoriatic patients and the overall effect in descending order was patient’s symptoms and feeling (with a total value of 541), treatment (with a total value of 287), daily activities (a total value of 232), and work and school (a total value of 54 (Table 4). The mean DLQI was 6.25 corresponding to a moderate effect and patient’s symptoms and feeling were the most affected domains of QoL.

Table 4

Quality of life (QoL) domains of psoriatic patients attending dermatologic clinic of ALERT Hospital, Addis Ababa, Ethiopia (N = 207).

Domains	Question Number	Mean	Minimum value	Maximum value	Total value
Symptoms and feelings	1	1.84	0	3	380
	2	0.78	0	3	161
Daily activities	3	0.22	0	3	45
	4	0.90	0	3	187
Leisure	5	0.23	0	3	47
	6	0.22	0	3	46
Work and School	7	0.25	0	3	51
		0.02	0	1	3
Personal relationships	8	0.31	0	3	64
	9	0.11	0	3	23
Treatment	10	1.39	0	3	287
Overall DLQI		6.25	0	29	1294

Factors associated with quality of life

Based on the results of univariate binary logistic regression analysis, variables such as gender, age group, educational status, occupation, family income, regular use of alcohol, BMI, age at initial diagnosis, and treatment modality were included in the multivariate binary logistic regression analysis. Accordingly, gender, educational status, family income, and treatment modality had a significant association with quality of life. The odds of having better QoL (DLQI≤5) for female patients was decreased by 83% [AOR = 0.17 (95% CI: 0.06, 0.48)], (P = 0.001). This study also found a significant association between primary educational status and poor quality of life [AOR = 0.14 (95% CI: 0.03, 0.64)] (P = 0.011). The odds of having better QoL (DLQI≤5) were more than four times higher among patients on systemic therapy as compared to those on topical only [AOR = 4.26 (CI:1.18,15.35)] (P = 0.027) (Table 5).

Table 5

Logistic regression analysis of factors associated with QoL among psoriasis patients attending dermatologic clinic of ALERT Hospital, Addis Ababa, Ethiopia (N = 207).

Variables	DLQI, n (%)		OR (95% CI)		P-value
	≤5	>5	Crude	Adjusted
Sex
Male	35 (41.18)	50 (58.82)	1.00	1.00
Female	82 (67.21)	40 (32.79)	0.34 (0.19,0.61)	0.17 (0.06,0.48)	0.001*
Age group
16–35	66 (62.26)	40 (37.74)	1.00	1.00
36–65	44 (58.67)	31 (41.33)	1.16 (0.64,2.13)	0.92 (0.33,2.60)	0.872
>65	7 (26.92)	19 (73.08)	4.48 (1.73,11.60)	5.50 (0.68,44.27)	0.109
Educational status
Can’t read and write	18 (46.15)	21 (53.85)	1.00	1.00
Primary	38 (82.61)	8 (17.39)	0.18 (0.07,0.49)	0.14 (0.03,0.64)	0.011*
Secondary	22 (50)	22 (50)	0.86 (0.36,2.03)	3.26 (0.65,16.50)	0.152
Higher	39 (50)	39 (50)	0.86 (0.40,1.85)	4.18 (0.75,23.62)	0.102
Occupation
Farmer	11 (45.83)	13 (54.17)	1.00	1.00
Merchant	33 (71.74)	13 (28.26)	0.33 (0.12,0.93)	0.87 (0.16,4.56)	0.865
Employee	27 (50.94)	26 (49.06)	0.82 (0.31,2.14)	1.28 (0.23,7.07)	0.774
Unemployed	5 (35.71)	9 (64.29)	1.52 (0.39,5.91)	1.89 (0.22,16.00)	0.560
House wife	14 (63.64)	8 (36.36)	0.48 (0.15,1.58)	4.80 (0.78,29.60)	0.091
Student	21 (72.41)	8 (27.59)	0.32 (0.10,1.01)	2.32 (0.26,20.80)	0.450
Daily laborer	4 (40)	6 (60)	1.27 (0.28,5.68)	5.48 (0.56,53.95)	0.145
Others	2 (22.22)	7 (77.78)	2.96 (0.51,17.30)	0.94 (0.04,20.11)	0.970
Monthly family income (ETB)
Very low ≤860)	10 (31.25)	22 (68.75)	1.00	1.00
Low (861–1500)	32 (76.19)	10 (23.81)	0.14 (0.05,0.40)	0.12 (0.02,0.56)	0.007*
Average (1501–3000)	8 (33.33)	16 (67.67)	0.91 (0.29,2.82)	0.24 (0.04,1.43)	0.117
Above average (3001–5000)	19 (59.38)	13 (40.62)	0.31 (0.11,0.87)	0.06 (0.01,0.32)	0.001*
High (≥5001)	48 (62.34)	29 (37.66)	0.28 (0.11,0.66)	0.03 (0.01,0.22)	<0.001*
Regular use of alcohol
No	115 (57.79)	84 (42.21)	1.00	1.00
Yes	2 (25)	6 (75)	4.11 (0.81,20.85)	8.05 (0.55,117.65)	0.128
BMI
Underweight	3 (20)	12 (80)	1.00	1.00
Normal	93 (58.86)	65 (41.14)	0.18 (0.05,0.64)	0.28 (0.06,1.36)	0.114
Overweight	7 (41.18)	10 (58.82)	0.36 (0.07,1.75)	0.86 (0.10,7.31)	0.889
Age at initial diagnosis (in years)
<40	90 (62.5)	54 (37.5)	1.00	1.00
≥ 40	27 (42.86)	36 (57.14)	2.22 (1.22,4.06)	1.82 (0.47,7.04)	0.384
Treatment modality
Topical	104 (59.43)	71 (40.57)	1.00	1.00
Systemic	7 (33.33)	14 (67.67)	2.93 (1.13,7.62)	4.26 (1.18,15.35)	0.027*
Topical and systemic	6 (54.54)	5 (45.46)	1.22 (0.36,4.15)	0.73 (0.10,5.61)	0.765

*- statistically significant at P<0.05.

Discussion

In this study, different medication regimens were used in the management of psoriasis. Topical corticosteroids were the most commonly prescribed medication followed by methotrexate in treating plaque psoriasis Likewise, different guidelines regarding the treatment of psoriasis vulgaris have shown that topical corticosteroids and methotrexate are one of the first lines for treating mild and moderate-severe psoriasis, respectively [21-23]. Corticosteroids can even be used as an adjunct to systemic therapy or phototherapy for moderate-to-severe psoriasis [5, 22] Among patients with plaque psoriasis, extemporaneous preparation of salicylic acid with topical corticosteroids was prescribed for 86 (59.3%) patients. Palmoplantar sebopsoriasis and scalp psoriasis were managed by topical corticosteroids alone or in combination with salicylic acid. This is in line with different clinical guidelines [23, 24].

Regarding the management of pustular psoriasis, the present study revealed that topical corticosteroids were commonly used treatment regimen. Contrastingly, National Psoriasis Foundation clinical guideline [24] did not state topical corticosteroids both as first and second-line therapy for treating such patients but rather recommended biologics. This might be due to unavailability of biologics and lack of local standard treatment guidelines for the management of psoriasis in Ethiopia. Extemporaneous preparation containing coal tar with topical corticosteroids was prescribed for 8 (3.9%) patients. South African guideline also recommends coal tar for management of patient s with mild psoriasis who require an inexpensive alternative to corticosteroids [22]. Furthermore, various guidelines also suggested that coal tar can be used for treating localized psoriasis, but it has poor tolerability by patients due to its irritation property, cosmetic issues like odor, and staining of clothes [5, 23, 25]. So, patients prescribed for coal tar need higher attention.

The present study reported a moderate effect of psoriasis on patients’ QoL, which is consistent with a hospital-based cross-sectional study done in India [26], Malaysia [27], and Russia [28]. However, Egyptian study found a higher mean DLQL, corresponding to a very large effect [29]. The first reason for this variation could be our study included all types of psoriasis, unlike the study done in Egypt which incorporated only psoriasis of chronic plaque-type and the second reason might be the difference in the severity of the disease among study participants as far as this study was carried out among outpatients only.

In the present study, only few patients replied that the disease has no effect on their QoL in consistent with a report of Indian study [26]. Among DLQI domains symptoms and feelings were the highly affected domain. The present result is in line with studies done in India [26, 30], Taiwan [31], and Egypt [29]. This is due to the fact that the domain encompasses questions directed to identify the level of embarrassment and painfulness or itchiness owing to the disease which is used to even define the disease in the case of global reports on psoriasis [8].

The identification of risk factors for a marked reduction in QoL owing to psoriasis is important as it helps to identify the most susceptible patient who requires close monitoring. The result of this study showed female gender was found to be independent predictors, which increases the chance of having poor QoL. This was supported by similar studies done in India [32], the United States of America [33], and Spain [34]. The probable reason could be the fact that females are more concerned about their body image and physical appearance than their male counterparts and they are more likely to feel troubled in public settings.

In this study, patients with primary education status, were significantly associated with poor QoL that is in contrary to a study done in India [35]. Such discrepancy might be a result of a difference in cultural settings, adjustment of confounding factors, DLQI cut-off point, and analysis model. Patients taking systemic therapy were significantly associated with less affected QoL which might be owing to its more aggressive, comfortable, and less time-consuming nature as compared to topical therapy. This result is supported by findings from a cohort study in Spain [34].

Our study had some limitations. The temporal relationship between the dependent and independent variables does not be allowed due to cross-sectional nature of the study design. The other limitation is that the drugs considered during analysis were those prescribed at the time of recent follow-up; it didn’t include drugs that were switched or withdrawn. This study also considered only pharmacologic interventions due to poor recording practice of the hospital.

Conclusions

Topical corticosteroids were the most prescribed treatment modality for psoriasis. Psoriasis moderately affected the QoL patients, patient’s symptoms and feelings being the most highly affected domain.

Questionnaire for patient interviews.

(DOCX)

Click here for additional data file.

Amharic version questionnaire.

(DOCX)

Click here for additional data file.

Data abstraction format for reviewing patient medical records.

(DOCX)

Click here for additional data file.

21 Jul 2021

PONE-D-20-33787

Management practice, and quality of life and its associated factors among ambulatory psoriatic patients attending Dermatological Center in Addis Ababa, Ethiopia

PLOS ONE

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PLOS ONE

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Reviewers' comments:

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Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Partly

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: In this manuscript for a research article, authors investigated the clinical care, quality of life and various associated factors of psoriatic patients managed at an outpatient clinic located in Addis Ababa, Ethiopia. As previous data published on the management of psoriasis in East Africa is very limited, the topic and findings of this paper is interesting. However, there are some major issues to be clarified by the authors.

Major remarks:

1. The exact inclusion and exclusion criteria of this study should be described instead of just reporting general eligibility criteria.

2. It is very surprising data that only 2.9% of the patients had comorbid diseases. Were the general medical records of the patients also reviewed? These data should be also discussed.

3. It should be described in the Introduction, which topicals, drugs and biologics are available for the treatment of psoriasis in Ethiopia, as treatment choices also highly depends on the availability of medications.

4. In the Discussion, it its not necessary to describe how corticosteroids and methotrexate work but would be important to compare the used treatment modalities to those of other regions and countries. Also, the benefits and limitations of inexpensive treatment options such as coal tar ointments should be discussed.

Minor remarks:

1. In the abstract, it is not necessary to include technical details, such as the name of the exact statistical software used for data analysis.

2. In the Introduction, epidemiologic data of psoriasis is only mentioned for Asia and Europe. It would be more appropriate to describe epidemiologic data from Africa. Also, previous papers describing the care for psoriatic patients in East Africa should be cited here.

3. In the Study setting section, it is confusing that only some general facts on the department, such as when it was established and in which medical specialties it is a leading center is reported. The prospective nature of the study should be described here.

4. The price of each treatment option should be also discussed in addition to their benefit in QOL, especially as the income of the patients was also reported.

5. Further conclusions should be added based on the observations of this study instead of repetition of the results.

Reviewer #2: The data support the conclusions, but for some of the statistical analyses, groups selected for O.R. 1.00 should be groups with a higher number of subjects for to increase the reliability of the results, and possibly avoiding errors, as mentioned in my comments. It is not likely, though, that this improvement will change the conclusions.

This is an interesting, informative and useful article, but it needs some changes.

Major concern:

When comparing groups, the largest group should be the basic group to compare with. Special caution is important when the reference group, with an O.R. of 1.00, is small. The result of switching to the largest group or the largest group at another end of a scale (for instance high income vs. low income) may change results and conclusions, although it is not likely that the main conclusions will be changed.

Reference to the first article from 1994 about DLQI values in healthy subjects, or another article including control or healthy subjects, should have been described explicitly, but briefly, with some numbers. What is a “normal” DLQI?

Preferable changes:

In the main text or as supportive information or footnotes, the variables used for adjustment should be indicated. If all variables of the independent ones is used except for the result variable (not preferable), this should be indicated. Huber’s stepdown procedure, letting age and gender remain as correction factors, is a feasible solution. If you adjust for non-significant variables, important results may be lost. However, age group and gender should always be adjusted for. However, using p<0.25 for selecting initial variables for adjustment, as you did, is common and preferable.

The distribution of results, as with spreadsheets or histograms, should have be shown. These findings could also be included as supportive information online. This way, one could see that the work is properly done without being obliged to read everything.

Minor concerns:

See some of the remarks added to the text file.

Recommendation in the case of further studies:

When dealing with data with a continuous outcome or more than two outcomes, ordinary regression, or, if the outcome is not normally distributed, and also appropriate if the data are normally Distributed, robust regression is preferable.

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6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

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Reviewer #1: No

Reviewer #2: Yes: Leif Bjarte Rolfsjord

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

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Submitted filename: PONE-D-20-33787_review.docx

Click here for additional data file.

Submitted filename: PONE-D-20-33787 with remarks.pdf

Click here for additional data file.

13 Oct 2021

First of all, the authors would like to greatly appreciate and respect for the time and efforts of reviewers of this manuscript for the careful reading and comments on the manuscript, which helped us to improve the manuscript. We have seen all comments carefully and explained at our level best in point-wise manner and incorporate the accepted comments in the revised version of the manuscript. We have given response to the comments made by the editor and reviewer(s) as follows. We tried to prepare the revised manuscript based on PLOS ONE's style requirements.

Point by point responses to reviewers’ comments:

REVIEWER 1

Major remarks:

1. The exact inclusion and exclusion criteria of this study should be described instead of just reporting general eligibility criteria.

Response: We accept comment provided from the reviewer and included inclusion and exclusion criteria in the revised manuscript as suggested by the reviewer

2. It is very surprising data that only 2.9% of the patients had comorbid diseases. Wre the general medical records of the patients also reviewed? These data should be also discussed.

Response: All medical records of the patients were reviewed and we also discussed the data. Since these patient come to the center manly for dermatological conditions management, they may have follow ups at other health facilities in the country. We included all co-morbidities we obtained from our review

3. It should be described in the Introduction, which topicals, drugs and biologics are available for the treatment of psoriasis in Ethiopia, as treatment choices also highly depends on the availability of medications.

Response: We accept this comment, included treatment options for psoriasis in Ethiopia.

In the Discussion, it is not necessary to describe how corticosteroids and methotrexate work but would be important to compare the used treatment modalities to those of other regions and countries.

4. Response: We accept this comment and deleted statements which described about how corticosteroids and methotrexate work. Furthermore, we tried to compare, the used treatment modalities to those of other regions and countries as indicated on the first paragraph of discussion.

Also, the benefits and limitations of inexpensive treatment options such as coal tar ointments should be discussed.

Response: We included about this on first paragraph of discussion as indicated below

Guideline on the management of psoriasis in South Africa showed that coal tar is recommended in patients with mild psoriasis who require an inexpensive alternative to corticosteroids [21]. Various guidelines also exposed that coal tar can be used for treating localized psoriasis, but it has poor tolerability by patients due to its irritation property, cosmetic issues like odor, and staining of clothes [5, 19,23]. So, patients prescribed for coal tar need higher attention.

Minor remarks:

1. In the abstract, it is not necessary to include technical details, such as the name of the exact statistical software used for data analysis.

Response: We removed name of the exact statistical software used for data analysis

2. In the Introduction, epidemiologic data of psoriasis is only mentioned for Asia and Europe. It would be more appropriate to describe epidemiologic data from Africa.

Response: We accept this comment, but unable to describe it as there is no epidemiological data of psoriasis in Africa

Also, previous papers describing the care for psoriatic patients in East Africa should be cited here.

Response: We have included this in the revised manuscript

3. In the Study setting section, it is confusing that only some general facts on the department, such as when it was established and in which medical specialties it is a leading center is reported. The prospective nature of the study should be described here.

Response: We already included about nature of the study under study design and period section.

4. The price of each treatment option should be also discussed in addition to their benefit in QOL, especially as the income of the patients was also reported.

Response: We didn’t discuss the price of the medications as far as it various from time to time and also mostly medications were out of stock at the studied center.

5. Further conclusions should be added based on the observations of this study instead of repetition of the results.

Response: We revised our conclusion both in abstract and main text according to this comment.

REVIEWER 2

The data support the conclusions, but for some of the statistical analyses, groups selected for O.R. 1.00 should be groups with a higher number of subjects for to increase the reliability of the results, and possibly avoiding errors, as mentioned in my comments. It is not likely, though, that this improvement will change the conclusions.

This is an interesting, informative and useful article, but it needs some changes

Response: We take this recommendation, however from our limited experience in data analysis which need such computing we use both ways i.e. why we did in other way round.

Major concern

When comparing groups, the largest group should be the basic group to compare with. Special caution is important when the reference group, with an O.R. of 1.00 is small. The result of switching to the largest group at another end of scale (for instance high income vs. low income) may change results and conclusions, although it is not likely that the main conclusions will be changed.

Response: As far as we developed the questionnaire prior to data collection, which we did in ascending order, it is impossible to take the middle as a control group and to do such it requires the data to be entered newly which as finding is no changed. The main thing here is that, knowing the reference and being in caution while interpreting the results. We did this carefully during data analysis. A mentioned by reviewer, the main conclusions will not be changed.

Reference to the first article from 1994 about DLQI values in healthy subjects, or another article including control or healthy subjects, should have been described explicitly, but briefly, with some numbers. What is a ‘normal’ DLQI?

Response: The normal DLQI means the disease has no impact on the patient, which is DLQI score of 0-1 as also indicated by no effect as shown in our data collection tool section of manuscript .

Preferable changes

In the main text or as supportive information or footnotes, the variables used for adjustment should be indicated. If all variables of the independent ones are used except for the result variable (not preferable), this should be indicated. Huber’s stepdown procedure, letting age and gender remain as correction factors, is a feasible solution. If you adjust for non-significant variables, important results may be lost. However, age group and gender should always be adjusted for. However, using p<0.25 for selecting initial variables for adjustment, as you did, is common and preferable.

Response: We accept this comment and based on that experience we used p<0.25 for selecting initial variables for adjustment. We will take this advice for our future works. Thank you!

The distribution of results, as with spreadsheets or histograms, should have been shown. These findings could also be included as supportive information online. This way, one could see that the work is properly done without being obliged to read everything.

Response: We used included all results appropriately in this manuscript. We will include supportive information online as supplementary materials)

Submitted filename: Responses to Reviewers.docx

Click here for additional data file.

8 Nov 2021

Management practice, quality of life and associated factors in ambulatory psoriatic patients attending Dermatological Center in Addis Ababa, Ethiopia

PONE-D-20-33787R1

Dear Dr. Tadesse,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Filipe Prazeres, MD, MSc, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: I thank the authors for carefully addressing all or the raised issues. I find the revised manuscript to show a significant improvement regarding both the presentation and the interpetation of data.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

10 Nov 2021

PONE-D-20-33787R1

Management practice, quality of life and associated factors in psoriasis patients attending a Dermatological Center in Ethiopia

Dear Dr. Tadesse:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Prof. Filipe Prazeres

Academic Editor

PLOS ONE