The Burden of Psoriasis in China and Global Level from 1990 to 2019: A Systematic Analysis from the Global Burden of Disease Study 2019.

Objectives: Psoriasis is a skin disease thought to be related to immune system dysfunction. Our study is aimed at analyzing the prevalence of psoriasis in China in multiple different categories and compared the prevalence at the global level, in order to bring insights to policymakers for treating this disease.
Methods: We analyzed psoriasis trends from 1990 to 2019 in China as well as around the globe with data from the Global Burden of Disease 2019 study. Multiple metrics such as age-standardized prevalence rates, percent change in age-standardized prevalence rates, disability-adjusted life years (DALYs), and age and sex patterns were included. We also predicted the trends of psoriasis prevalence and DALYs in the following 30 years.
Results: In China, the age-specific prevalence cases showed a right shift in 2019 compared to 1990 with a peak between the ages of 50 and 54 years and an obvious surpass in males between 40 and 69. Though China still had the largest number of psoriasis cases in 2019, the increase rate was below global level. A positive linear relationship between psoriasis prevalence and comorbidities was seen with rheumatoid arthritis, diabetes mellitus, multiple sclerosis, nonrheumatic valvular heart disease, cardiomyopathy and myocarditis, nonmelanoma skin cancer, non-Hodgkin lymphoma, and multiple myeloma in China within the male group in 2019. Discussion. The burden of psoriasis, as measured by the absolute number of DALYs, continues to increase around the world. The scarcity of modifiable risks for most psoriasis burdens suggests that new knowledge is needed to develop effective prevention and treatment strategies.

1. Introduction

Psoriasis is a chronic autoimmune skin disease which can happen at any age, with peaks of onset seen around 20 to 30 years and 50 to 60 years [1]. The origin of psoriasis is a consequence of genetic susceptibility and environmental triggers. The typical skin appearance of psoriasis is psoriatic plaques (erythematous, invasive, and exfoliative lesions) covering the psoriatic scales. The most common sites of psoriasis are on the hairy scalp, the extensor surfaces of the knees and elbows, and the sacral and lumbar regions. The characteristic symptoms of psoriasis also include nail lesions (nail lysis, oil spots, dents, and splinter bleeding) [2]. It has been reported the activation of the IL-23/Th17/IL-17 axis causes chronic inflammation, which results in hyperproliferation, altered differentiation, and activation of keratinocytes [3, 4], but their roles have not proven in humans. Psoriasis has multiple different types, including plaque, guttate, erythrodermic, inverse, nail, arthritis, and pustular psoriasis, among which plaque psoriasis is the most common type [5]. Severe psoriasis is associated with an increased risk of death from a variety of causes such as cardiovascular diseases, infection, kidney disease, and dementia [6, 7]. Psoriasis is common in the scalp, elbows, knees, torso, hips, nails, skin folds or hands, feet, and other parts and can increase the risk of other diseases, such as lymphoma, cardiovascular disease, the serious influence of patients, and others for their own treatment, increase the patient's physical, emotional, and social pressure, lead to depression rate which is higher, and affect the quality of life [1, 8–10]. The pathogenesis of psoriasis is complex and not yet fully understood. Although the current treatments have been shown to be effective, some patients do not respond, or they develop resistance to the treatment over time, or their disease relapses when the treatment is stopped [11]. Therefore, continued efforts are needed to understand the pathologic mechanisms that may occur in psoriasis, including the identification of novel molecules that can be targeted alone or in combination with existing therapies.

In 2019, the worldwide around 40 million people were suffered from psoriasis, among which 4.6 million were new cases [12, 13]. According to GBD 2019 study, the prevalence of psoriasis varies between 0.09% and 3.34% in different countries, with 2.11% in European Union, 0.22% in African Union, and 0.56% in China. Psoriasis has a great financial burden on patients as well as society. In US, it is estimated that the total annual cost for treating psoriasis is between 1.6 to 4.3 billion dollars around 2000, and the total economic burden is up to be 120 billion for 2013 [14].

China has the world's largest population, and the most prevalent cases of psoriasis as well. But so far, the epidemiological study of psoriasis in China is limited [15, 16]. In this observational study, we analyzed data from GDB 2019 study. We showed the prevalence in China from 1990 to 2019 and compared it with global trends including age and sex patterns. We also analyzed psoriasis burden through DALYs, and we provided associations between psoriasis and multiple associated comorbidities in G20 countries and global level. To our knowledge, our study is the most recent and has not yet been reported in the GBD 2019 research database. Meanwhile, we predicted the trends of psoriasis prevalence and DALYs in the following 30 years in China as well as around the globe.

The aims of this study were to investigate the prevalence of psoriasis in China, to reveal the relationship between psoriasis and multiple comorbidities in women and men, and to predict the future prevalence of psoriasis through GBD 2019 database. This study is necessary, as China is the country with the largest population and most psoriasis cases. The analysis is based on the GBD 2019 study, which is one of the largest scientific collaborations in the world and the most comprehensive, high-quality effort of measuring global epidemiologic levels and trends. Our study would provide insights to the public on the awareness of psoriasis and its relationship with other diseases and to the policymakers for reference when making policies and taking actions.

2. Methods

2.1. Data Source

Data was queried from the 2019 GBD database (http://ghdx.healthdata.org/gbd-results-tool), with prevalence and DALYs of psoriasis and deaths of comorbidities during 1990 to 2019 by sex, age, and location. The 2019 GBD study provides comprehensive epidemiological estimates on prevalence, incidence, mortality, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life years (DALYs) of diseases and injuries for each sex, age group, country, and territory, etc. [12, 13, 17]. DALYs represent a combined measure of health loss from both nonfatal and fatal outcomes, equal to years of life lost (YLLs) plus years lived with disability (YLDs). YLLs are calculated as the product of number of deaths caused by psoriasis and a standard remaining life expectancy at the age of death. YLDs are estimated by multiplying psoriasis prevalence with the corresponding disability weights. The detailed methods for data gathering, processing, and modeling were described extensively in the GBD 2019 studies. The projected world population data is available on the United Nations website (https://population.un.org/wpp/Download/Standard/Population/). WHO 2000-2025 world Standard Population Distribution is available on the WHO website (https://www.who.int/healthinfo/paper31.pdf).

2.2. Study Design

A cross-sectional analysis of psoriasis prevalence between 1990 and 2019 in China and the globe in different age groups and different sexes was performed to show the change over the past 30 years. A longitudinal analysis of psoriasis prevalence during 1990 to 2019 was performed to show the trends over the past 30 years.

2.3. Predicting Prevalence Cases and DALYs

The autoregressive integrated moving average (ARIMA) model was used to predict the number of prevalence cases and DALYs for psoriasis during 2020 through 2039 by using “tidyquant” package in R (https://github.com/business-science/tidyquant) [18]. The mean absolute error (MAE) and root mean square error (RME) were used to summarize the model performance for 24 weeks of historical data used to fit the model. The selected ARIMA model (0, 0, 1) has the lowest MAE and RMSE.

2.4. Statistical Analysis

Statistical analyses of the correlations between the death rate of diseases and the prevalence rate of psoriasis were performed using Pearson's coefficient, r, with R package “ggpubr.” The bar graphs and heatmaps were drawn with the package “ggplot2.”

3. Results

Our results indicated the prevalence rate in male was higher than female in the past 30 years. Besides, the prevalence rate peaks at earlier ages in males compared to females. There is further analysis of the correlation between psoriasis and other diseases in China. In addition, the DALYs for psoriasis would increase in Global while decrease in China.

Globally, the age-specific prevalence cases in 2019 were slightly decreased in young people, while was increased in people greater than 25 years old, with a peak between 50 and 54 years old (Figure 1(a)). In China, prevalence cases were decreased in 2019 among people less than 29 years old. The prevalence case had a peak between 50 and 54 years old (Figure 1(b)). The age-specific prevalence rate was decreased in 2019 in China, as well as around the world (Figures 1(a) and 1(b)). Globally, the females had a slightly higher prevalence rate before 34 years and less prevalence rate in elder ages compared to males (Figure 1(c)). In China, the females had a higher prevalence rate before 34 years old and after 70 years old, and less prevalence rate was between 35 and 69 years old (Figure 1(d)). From 1990 to 2019, the psoriasis prevalence cases were increased annually in China and around the world. The overall prevalence rate was decreased continuously at the global level, while in China, the prevalence rate was fluctuated slightly in both females and males (Figure 2). Collectively, the overall prevalence rate was decreased continuously at the global level, while in China, the prevalence rate was fluctuated slightly in different age and gender.

Figure 1

Age patterns of the total number of prevalent cases and age-specific prevalence rates by year in globe (a) and in China (b). Age patterns of the total number of prevalent cases and age-specific prevalence rates by sex in 2019 in globe (c) and in China (d).

Figure 2

Year patterns of the total number of prevalent cases and age-specific prevalence rates by location (a). Year patterns of the total number of prevalent cases and age-specific prevalence rates by sex in globe (b) and China (c).

In 2019, China had the largest prevalence cases 7.65 million (95% UI: 7.39-7.91), followed by India with 4.8 million (95% UI: 4.63.6-4.96) (Figure 3(a)). Regarding the prevalence rate change between 1990 and 2019, Qatar had suffered the largest percent of increase with a number 455% (95% UI: 438%-472%), followed by United Arab Emirates with a number 381% (95% UI: 365%-399%). China had a change rate of 21% (95% UI: 19%-22%) (Figure 3(b)). When comparing the prevalence of psoriasis cases per 100,000 and the reported psoriasis comorbidities and some other autoimmune diseases morbidities (Supplemental date (available here)) per 100,000 in the past 30 years globally, a positive linear relationship was seen with mental disorders, Hodgkin lymphoma, leukemia, rheumatic heart disease, chronic obstructive pulmonary disease, and asthma (Figure 4(a)). However, in China, the females had different associations of psoriasis with the above diseases compared to males. A positive linear relationship was seen with nonmelanoma skin cancer, non-Hodgkin lymphoma, multiple myeloma, ischemic heart disease, cardiomyopathy and myocarditis, nonrheumatic valvular heart disease, multiple sclerosis, diabetes mellitus, and rheumatoid arthritis in male, while only strong positive relationship was seen in chronic obstructive pulmonary disease, asthma, cirrhosis and other chronic liver diseases, and inflammatory bowel disease in female (Figure 4(b)). In short, a positive linear relationship between psoriasis prevalence and comorbidities was seen with different diseases in China within the male group in 2019.

Figure 3

The total number of prevalent cases (a) in 2019, age-specific prevalence rates (b) in 2019, and prevalence cases changes between 1990 and 2019 (c) of psoriasis by countries and territories.

Figure 4

Correlation between the prevalence rate of psoriasis and the death rate of some reported psoriasis comorbidities or auto immune diseases in globe and G-20 countries (a) and in globe and China grouped by sex (b).

The projection of prevalence and DALYs for psoriasis at the global level and in China is shown in (Figure 5). In 2039, the prevalence number would increase to 46.18 million in global while decreasing to 6.78 million in China. The DALYs for psoriasis would increase to 3.91 million in global while decrease to 496.29 thousand in China. In a word, the DALYs for psoriasis would increase in global while decrease in China.

Figure 5

The projection of prevalence (a) and DALYs (b) for psoriasis in globe and China.

4. Discussion

The prevalence cases and associated DALYs of psoriasis in China and globe were continuously grown during 1990-2019. The global percentage of psoriasis prevalence was decreased from 0.61% in 1990 to 0.55% in 2019, while the percentage of psoriasis prevalence in China was quite stable from 1990 to 2019 (Table 1). Consistent with previous study [19], our paper also showed that the age-specific prevalence rate was decreased in 2019 in China, as well as around the world. Though prevalence cases in both female and male groups increased in China and around the globe, the trends of prevalence rate in China during 1990-2019 were different from that around the globe. Around the globe, the prevalence rate in female was higher than male, and the gap was shrinking from 1990 to 2019, and the prevalence rate almost converged in 2019. However, in China, the prevalence rate in male was higher than female, and the difference gap was increasing from 1990 to 2019. Intriguingly, a study proposed by Iskandar et al. have indicated that the incidence and prevalence of psoriasis is varied by age and gender [20], which further supports our fining.

The prevalence rate varies in different age groups in China and around the globe. In both China and the globe, the prevalence cases peak at 50 to 54 years in 2019, while the prevalence rate peaks at 65 to74 years. Both female and male groups had similar age pattern in globe, but in China, male group and female groups differ greatly in different age groups. In China, the prevalence rate of male peaks earlier at 55 to 59 years, while the prevalence rate of female peaks at 75 to 79 years. In agreement with the previous studies, our results showed psoriasis spread widely around the world, but the prevalence rate is lower in tropical countries than those farther from the equator [7]. In addition, we have shown the western countries have a much higher prevalence rate than Southeast Asian countries and African countries. In line with our results, it has been reported that the incidence of psoriasis is more frequent in high income countries and in regions with older populations [21]. The disparity is possibly partially due to genetic reasons. In addition, as most countries in Southeast Asia and Africa are less-developed countries, citizens in these countries might not be aware of the illness, and the cases were not reported.

Previously, studies showed psoriasis is associated with cardiovascular disease [7]. We conducted a longitudinal analysis to analyze the association between psoriasis prevalence and some cardiovascular disease-related deaths around the globe and in G20 countries. The East Asia and Southeast Asia countries show very similar patterns in associations between psoriasis and cardiovascular diseases. Death rate of ischemic heart disease, cardiomyopathy, and myocarditis and nonrheumatic valvular heart disease were positively correlated to the prevalence rate of psoriasis in countries such as China, South Korea, Japan, Indonesia, and Mexico. In China, female showed different correlation pattern between psoriasis prevalence and cardiovascular disease-related death rate from male. Besides cardiovascular disease, we found psoriasis prevalence rate was positively associated with non-Hodgkin lymphoma and multiple myeloma in China, South Korea, Japan, Indonesia, Mexico, and Brazil, but was negatively associated in globe. This result indicates, to analyze the associations in disease levels, it may be better analyzing in individual country, as different region or country has different economic, social, and behavior factors. Consistently, it has been proved that psoriasis is associated with increased risk for cardiovascular disease, diabetes mellitus, obesity, inflammatory bowel disease, and nonalcoholic fatty liver disease [22].

There are some important limitations regarding the burden of psoriasis around the globe, as well as in individual countries. The terminology, criteria, and methodologies used to study psoriasis in different projects are different, making it difficult to compare the results across studies. In addition, different countries or regions have different data coverage. For example, in developed countries, patients may be diagnosed with psoriasis at the origin of the disease, while in less-developed countries, patients were not diagnosed until the symptom is very serious. The differences in data collections make it difficult to compare across projects. In addition, as the study was performed in epidemiological perspective, we did not have detailed insights regarding the mechanism of origin of psoriasis and its association with other diseases.

In summary, our study analyzed the prevalence of psoriasis in China in multiple different categories and compared the prevalence at the global level. We found the prevalence rate in male was higher than that in female, and the gap was increasing in the past 30 years. In addition, the prevalence rate peaks at earlier ages in males compared to females. Further analysis of the correlation between psoriasis and other diseases reveals that in China, the death rates of nonmelanoma skin cancer, non-Hodgkin lymphoma, multiple myeloma, ischemic heart disease, cardiomyopathy and myocarditis, nonrheumatic valvular heart disease, multiple sclerosis, diabetes mellitus, and rheumatoid arthritis were positively correlated to psoriasis in male, and death rates of inflammatory bowel disease, cirrhosis and other chronic liver diseases, and asthma were positively correlated with psoriasis in female. So, regarding the above results, we suggest policymakers take different actions when making policies for different age groups and genders.

(a)

Characteristics	1990
	All ages no.×103 (95% UI)	Adolescent no.×103 (95% UI)	20-55 no.×103 (95% UI)	55 plus no.×103 (95% UI)	ASR per 100,000 no.×103 (95% UI)
Global
Both	31585.43 (30534.51-32628.38)	5352.04 (5043.61-5698.88)	16912.8 (16157.97-17661.23)	9320.59 (8911.25-9782.55)	660.22 (637.42-681.47)
Female	16018.77 (15482.37-16544.06)	2862.14 (2699.38-3047.46)	8276.86 (7903.11-8649.47)	4879.78 (4669.68-5114.38)	657.86 (635.71-679.03)
Male	15566.65 (15031.01-16080.61)	2489.9 (2346.61-2655.24)	8635.94 (8239.57-9015.96)	4440.82 (4235.44-4660.91)	662.7 (639.35-683.78)
China
Both	6335.48 (6103.05-6560.48)	1026.99 (963.64-1096.48)	3683.09 (3510.17-3856.87)	1625.39 (1547.5-1713.34)	577.92 (556.62-597.26)
Female	2996.48 (2888.22-3107.76)	579.37 (543.13-618.2)	1705.02 (1622.19-1788.5)	712.1 (677.59-750.3)	549.27 (529.62-568)
Male	3338.99 (3214.42-3460.59)	447.62 (420.28-479.16)	1978.08 (1885.07-2067.78)	913.29 (864.83-963.45)	601.65 (578.73-622.6)

(b)

Characteristics	2019
	All ages no.×103 (95% UI)	Adolescent no.×103 (95% UI)	20-55 no.×103 (95% UI)	55 plus no.×103 (95% UI)	ASR per 100,000 no.×103 (95% UI)
Global
Both	40805.39 (39421.38-42076.75)	5010.35 (4720.49-5344.08)	20928.06 (19983.16-21848.87)	14866.97 (14224.12-15561.58)	503.62 (486.92-519.22)
Female	20356.5 (19672.49-20990.7)	2618.98 (2470.07-2789.4)	10206.11 (9739.65-10644.28)	7531.41 (7210.12-7872.17)	497.55 (481.1-513.08)
Male	20448.88 (19749.82-21083.37)	2391.37 (2255.56-2554.03)	10721.95 (10241.45-11186.42)	7335.56 (7018.88-7685.5)	510.67 (493.44-526.4)
China
Both	7653.27 (7385.81-7908.31)	507.42 (477.44-540.66)	4146.3 (3949.07-4337.9)	2999.55 (2862.15-3151.37)	434.82 (420.27-448.33)
Female	3478.99 (3361.97-3591.07)	278.07 (261.29-296.54)	1858.25 (1773.71-1941.59)	1342.67 (1281.53-1408.24)	415.41 (401.69-428.06)
Male	4174.28 (4016.31-4319.14)	229.35 (215.77-244.69)	2288.05 (2181.72-2393.98)	1656.88 (1578.42-1745)	454.78 (438.22-469.42)

(c)

Characteristics	Continued 1990-2019
	All ages change no. (95% CI)	Adolescent change no. (95% CI)	20-55 change no. (95% CI)	55 plus change no. (95% CI)	ASR change no. (95% CI)
Global
Both	0.29 (0.28 to 0.3)	-0.06 (-0.07 to -0.06)	0.24 (0.23 to 0.25)	0.6 (0.59 to 0.6)	-0.24 (-0.24 to -0.23)
Female	0.27 (0.26 to 0.28)	-0.08 (-0.09 to -0.08)	0.23 (0.22 to 0.24)	0.54 (0.53 to 0.55)	-0.24 (-0.25 to -0.24)
Male	0.31 (0.3 to 0.32)	-0.04 (-0.05 to -0.03)	0.24 (0.23 to 0.25)	0.65 (0.64 to 0.66)	-0.23 (-0.23 to -0.23)
China
Both	0.21 (0.19 to 0.22)	-0.51 (-0.51 to -0.5)	0.13 (0.1 to 0.15)	0.85 (0.83 to 0.87)	-0.25 (-0.25 to -0.24)
Female	0.16 (0.14 to 0.18)	-0.52 (-0.53 to -0.51)	0.09 (0.07 to 0.11)	0.89 (0.86 to 0.91)	-0.24 (-0.25 to -0.24)
Male	0.25 (0.23 to 0.27)	-0.49 (-0.5 to -0.48)	0.16 (0.13 to 0.18)	0.81 (0.79 to 0.84)	-0.24 (-0.25 to -0.24)