Dermatology

1. JOURNAL CLUB

2. 1. Current Situation of Leprosy in India and its
Future Implications.
2. Newer Topical Treatments in Skin and Nail
Dermatophyte Infections.
3. Correlation between Disease Severity,
Family Income, and Quality of Life
in Psoriasis: A Study from South India

3. Current Situation of Leprosy in India and its
Future Implications

4. INTRODUCTION
• Despite advances in all spheres of
medical science, leprosy continues to be
a public health challenge in countries like
India.
• The current situation of leprosy in India in the
context of the world and includes the
successes, new initiatives, challenges, and
future implications for leprosy control in India.

5. Global Leprosy Situation
• The WHO launched a 5-year “Global
leprosy strategy 2016– 2020’ in April 2016
titled ‘accelerating towards a leprosy-free
world’.”
This was built on the earlier 5-year strategy
2011–2015 that focused on
early leprosy detection to reduce disabilities.

6. • The document states that the agenda of
eliminating leprosy at the subnational
level is still unfinished in many countries
and will therefore continue to be pursued
in the coming years.
• Other challenges –
• continued delay in detecting new patients,
persisting discrimination against people
affected by leprosy, and
limited impact on transmission of leprosy.

7. • the strategy for years 2016–2020 is built around
three pillars:
(i) to strengthen government
ownership, coordination, and partnership;
(ii) to stop leprosy and its complications;
(iii) to stop discrimination and promote
inclusion.
There is a special focus on
• women and children,
• strengthening referral systems,
• more effective contact tracing,
• assessing the value of chemoprophylaxis,
• and monitoring drug resistance

8. • The latest update from the WHO
titled “Global leprosy update, 2016:
accelerating reduction of disease burden:
states that –
although there has been a
significant reduction in prevalence of the
disease worldwide since the mid-1980s to
elimination levels, new cases continue to arise
indicating continued transmission.
• The global prevalence at the end of 2016 was 171,948
with a registered prevalence rate of 0.23 per 10,000
population, a decrease from that in 2015.
• The NCD in the year, however, was 214,783, a marginal
increase compared to 2015 .

9. Current Situation of Leprosy in India
• In India, the National Leprosy Eradication Programme
• (NLEP) is the centrally sponsored health scheme of the
• Ministry of Health and Family Welfare, Government of
• India.
• While the NLEP strategies and plans are formulated
• centrally, the programme is implemented by states and
• union territories (UTs).
• The programme is also supported by
• WHO, ILEP, and few other nongovernmental organizations
• (NGOs).
• Due to their efforts, from a prevalence rate
• of 57.8/10,000 in 1983, India has succeeded with the
• implementation of MDT in bringing the national prevalence
• down to “elimination as a public health problem” of less
• than 1/10,000 in December 2005 and even further down to
• 0.66/10,000 in 2016.

10. • In addition to achieving the national elimination target by
the end of 2005,
India by the end of March 2011–2012 succeeded in achieving
elimination at the state level in 34 states/UTs out of the total
of 36 states/UTs.
Only the state of Chhattisgarh and the UT of Dadra & Nagar
Haveli were yet to achieve elimination.
• By the end of March 2016, 551 districts (82.36%), out
of the total 669 in districts, in India had a prevalence
of <1/10,000 population which is the target of elimination
as a public health problem.
• The number of districts with
prevalence between 1 and 2/10,000 were 76, number of
districts with prevalence between >2 and 5/10,000 were 39,
and those between 5 and 10 were 2.

11. • Despite the above successes, the fact remains that India
continues to account for 60% of new cases reported
globally each year and is among the 22 “global priority
countries” that contribute 95% of world numbers of leprosy
• In the year 2007, new cases detected in India were
137,685, and nine years later in 2016, the number
remained almost the same at
135,485, a significant increase over the 127,326 new cases
detected in 2015.
• This increase in new cases is attributed by NLEP to their
recent strategy of innovative Leprosy Case Detection
Campaign (LCDC), which resulted in the detection of 34 000
new cases in 2016 from highly endemic
pockets, which accounted for 25% of annual new cases.

12. • Of the total new cases detected, almost 50%
were multibacillary leprosy and the child rate was
about 8.7%, which was similar to the previous
year’s figures, both indicating continued
transmission of leprosy in the community.
• LCDC also resulted in increasing the number of
districts with a prevalence of >1/10,000 in the
country, reminding us of the value of active case
finding strategies

13. • NLEP annual reports of the last 4 years have
consistently
observed that the four states/UTs (Orissa, Chandigarh,
Delhi, and Lakshadweep), which achieved elimination
earlier in 2011–2012, have shown a prevalence of >1 per
10,000 population, which is a matter of concern for the
programme.
In addition, although the average national child leprosy
rate is approximately 9%, the proportion of child cases
was more than 10% of new cases detected in eleven
states/UTs of India, with 6 of them (Tamil Nadu,Punjab,
Dadra & Nagar haveli, Bihar, Mizoram, and Arunachal
Pradesh) showing very high rates ranging from 14% to
23%. In a few of these states, the high multibacillary
proportion, and in others a difficult to reach terrain could
contribute to continued transmission.

14. Present and Future National Strategy
for Leprosy
The NLEP in its recent evaluation have acknowledged that there
are cases occurring in the community and detection
capacity is not matching the level and intensity of disease
occurrence. The office of the Dy. Director General for leprosy
(India) in a directive in August 2016 drew attention to the
following four alarming trends.
1. There are pockets of high endemicity in the country where
there is ongoing transmission.
2. There are many hidden cases in the community as revealed
by the sample survey conducted by Indian Council for
Medical Research (ICMR).
3. The new case detection rate has remained almost the same
since 2005.
4. The disability rates in new cases has been rising due to a
delay in diagnosis.

15. • To address these challenges NLEP advocated a
three-pronged approach
(a) “leprosy case detection campaign (LCDC)” in
highly endemic districts;
(b) focused leprosy awareness campaign
using ASHA and multipurpose healthworkers
in “Hot Spots,” where new cases with
Grade2 Disability (G2D) are detected;
(c) area-specific plans for case detection
in hard to reach areas.

16. • Government initiated LCDCs, initially in 50 highly
endemic districts of seven states –
Bihar, Chhattisgarh, Jharkhand,
Madhya Pradesh, Maharashtra, Odisha
& Uttar Pradesh, through
active search methods.
• By the end of year 2016 a total of 163 highly
endemic districts, which reported a prevalence
rate >1/10,000 population in any of the last 3
years, were identified for
conducting case detection campaigns by NLEP

17. • The SPARSH LeprosyAwareness Campaign (SLAC)
was launched on 30th January 2017
program intended to promote awareness and
address the issues of stigma and discrimination.
• The anticipation of the present strategy is that, with
increasing awareness and reducing stigma, more hidden
cases will self-report for diagnosis and treatment.
The special emphasis on women,children, and those with
disabilities is expected to flush out more hidden cases.
In addition to continuing to administer
MDT to patients, new preventive approaches such as
chemoprophylaxis and immuno-prophylaxis are being
considered to break the chain of transmission and reach
zero disease status.

18. Chemoprophylaxis of contacts
• A randomized control study has shown that
chemoprophylaxis with single dose rifampicin (SDR)
has a 57% overall risk reduction in preventing the
development of leprosy for household contacts
during the first 2 years after its administration.
• the protective effect of SDR was seen only in the
first 2 years, with no additional effect after 4 and
6 years.

19. • Leprosy Post Exposure Prophylaxis (LPEP) was launched
globally in the year 2014
The program has three prime components –
contact tracing and screening and single-dose rifampicin (SDR)
administration.
• Once a new patient has been diagnosed, health services actively
screen household members and neighbours of the patient and
examine them.
• Symptomatic persons are promptly referred for MDT and
asymptomatic “contact persons” are offered a post-exposure
prophylaxis (single-dose rifampicin) to
reduce their risk of developing leprosy by 50–60%.

20. • Contact of leprosy for this programme is defined
as someone who has had prolonged regular or
interrupted contact with an index case during the
last 1year.
• A single dose of 600 mg of rifampicin is
advocated as LPEP to household contacts above
35 kg body weight, 450 mg to individuals of 20 to
35 kg weight, and for those with <20 kg body
weight, 10–15 mg/kg of rifampicin as single dose.

21. • A double-blind, randomized, placebo-controlled trial in northwest
Bangladesh has observed that chemoprophylaxis with single-dose
rifampicin given to contacts of newly
diagnosed leprosy patients is a cost-effective intervention
strategy.
• there is a potential risk of rifampicin resistance emerging in
community due to SDR.
• a group of multidisciplinary experts in leprosy
and tuberculosis after carefully reviewing the available
evidence concluded that SDR given to contacts of leprosy
patients, in the absence of symptoms of active TB,
poses a negligible risk of generating resistance in
M. tuberculosis in individuals and at the population level.
• LPEP is now operational in Indonesia, India, Nepal, Myanmar,
Tanzania, and Sri Lanka and in a modified way in Brazil and
Cambodia

22. • . As per the current planning, LPEP will continue until
2018 with ongoing data collection to generate
evidence on the most efficient way to operationalize
contact tracing with post-exposure prophylaxis and its
potential to interrupt leprosy transmission.
• In India at present, a study is under progress in the
union territory of Dadra and Nagar Haveli to assess the
feasibility of administration and acceptance of single
dose of rifampicin chemoprophylaxis.
• NLEP is also proposing to launch chemoprophylaxis
with rifampicin in districts where LCDC is ongoing.

23. MiP Immuno-Prophylactic Vaccine
• NLEP has introduced the Mycobacterium Indicus Prani
(MiP) vaccine in a project mode in India from the
year 2016.
• MIP vaccine has been shown to have both
immunotherapeutic and immune-prophylactic effects
in multibacillary leprosy patients and their contacts.
• It also reduced the bacillary load, upgraded the lesions
histopathologically,led to complete clearance of
granuloma, reduced reactions, and neuritis and
reduced the duration of MDT in leprosy patients.

24. • In the new field project undertaken under ICMR and
NLEP, the index leprosy patient will receive the MIP
vaccine over and above the MDT.
• His family members and contacts would be immunized
with MIP twice at an interval of 6 months with the
expectation that their immunity is reinforced .
• The utility of immunizing the index case is for rapid
clearance of bacteria and clinical lesions.
• In contacts, MiP vaccination upgrades their immunity,
thereby
• resisting the development of the clinical disease on
exposure to M. leprae from those suffering from it.

25. NIKUSTH
• Nikusth, a web-based reporting system for
leprosy
• For the ease of reporting and data management
of registered leprosy cases, NLEP has launched
“Nikusth,” a web-based reporting system in India.
• In addition, “Nikusth” will be helpful in keeping
track of all the activities being implemented
under the NLEP.
• NLEP is also planning to develop online training
software for leprosy workers.

26. Areas of Concern
• Despite all the initiatives mentioned above being taken by
NLEP, there are many reasons why there is no decline in
occurrence of new leprosy cases in India over last decade.
• the WHO elimination target has no epidemiological or
scientific basis or even significance to support the gradual
decline or disappearance of the remaining cases of leprosy
once it was achieved
• rapid merging of leprosy services into the general medical
health services,
• efforts towards further reducing the duration of therapy,
• reduced attention to research and funding of leprosy
programme
are some of the direct effect of such false interpretation

27. Disability in new cases and their
continued occurrence
• For global leprosy, G2D among newly detected cases,
whose reduction is an important indicator for the
success of the program,
was 5,245 (3.8%) for the reporting year 2016.
• When compared to the previous year 2015, the global
disability rate reduced from 4.5% to 3.8%.
• Continued high G2D rate among new cases indicates
that leprosy is being detected late and there may be
hidden cases in the community.

28. • The G2D among child leprosy cases is also an important
indicator,
• WHO global leprosy statistics for the reporting year 2016
states that information on child G2D cases was available
from 210 countries,
• with 190 countries reporting zero child G2D cases and
• 14 countries reporting 281 cases, which does
not include numbers from India.
• NLEP report for year 2015–2016 mentions that,
out of the total 11,230 new child cases detected during
2015–16, the number of child cases with G2D was 162 (1.4%).

29. • One of the key reasons for the rise in disability
is a delay in diagnosis of leprosy and lepra
reactions which lead to persistent neuritis and
ultimately to disability.
• “Care after cure” that includes management
of trophic ulcers and other long-term
complications cannot be ignored.

30. Need for New Drug Regimen
• From its introduction in 1982 to till date, the same three
drugs constitute MDT for leprosy,
• with emerging resistance to these drugs, there is a need to
expand the drugs to treat leprosy.
• In 2016, India reported 536 cases of leprosy relapse, a
slight increase over the 459 reported in 2015.
• In 2016, India reported the largest number of retreatment
cases of 6701 and cure rates of paucibacillary 95.4% and
multibacillary cases 91.9%.

31. • Ofloxacin, minocycline, clarithromycin,
rifapentine, and moxifloxacin are some of the
drugs known to be effective in treatment of
leprosy.
• However, there are no standard
recommended/approved protocols to use
them, except in cases of proven resistance
to rifampicin.

32. • The efficacy of pulse rifampicin, ofloxacin, and
minocycline (ROM) as an alternative/additional
regimen to treat multibacillary leprosy patients
who refuse clofazimine needs to be evaluated.
• With increasing multibacillary leprosy load in the
community and severe forms of lepromatous leprosy
with high initial bacillary load being diagnosed across
the country, there is an urgent need to review the
current guidelines of “fixed duration therapy” (FDT) for
all types of multibacillary leprosy

33. • There is now a realization that in the past
there has been too much of an emphasis on
“numbers” – a point prevalence of the disease
and a new case detection rate rather than
other more important indicators of grade 2
disability, leprosy in the younger age group,
and multibacillary disease.

34. Newer Topical Treatments
in Skin and Nail
Dermatophyte Infections

35. • Treatment of dermatophytosis consists of oral or
topical antifungal drugs or a combination of both,
depending on the extent and severity, site of infection,
and causative organism.
• The main classes of topical antifungal drugs
include the polyenes, the azoles, and the
allylamine/benzylamines.
• Recently, various new antifungal drugs with increased
efficacy and associated anti-inflammatory effect have
been introduced in India

36. • A meta-analysis found no significant differences
among the topical antifungals in regard to clinical
and mycological cure at the end of the treatment.
• However, terbinafine and butenafine led to
sustained cure compared to clotrimazole.

38. AZOLES
• Azole antifungals are composed of two chemically related
groups, i.e., imidazoles and triazoles.
• Triazoles differ from imidazoles by having three nitrogen
atoms in the azole ring whereas imidazoles has two.
• They act by blocking the lanosterol 14α-demethylase, an
enzyme necessary for the biosynthesis of ergosterol.
Ergosterol is the primary sterol derivative which is an
essential component of the fungal cell membrane.
• Decreased levels of ergosterol in cell membrane and
accumulation of intracellular 14α-methylsterols lead to
increased membrane rigidity, increased membrane
permeability, disruption of membrane-bound enzymes,
inhibition of growth, and ultimately cell death

39. • Sertaconazole, has both fungistatic and fungicidal activity
depending on the concentration of the drug and the specific
organisms involved in the infection.
• At higher concentration, it directly binds to nonsterol lipids
in the fungal membrane leading to increased permeability
and rapid leakage of key intracellular constituents to such
an extent that immediate cell death ensues. It has
broad-spectrum antifungal activity against all three genera
of dermatophytes, Candida and Cryptococcus.
• Sertaconazole 2% cream was approved by the FDA in 2003
for the treatment of tinea pedis caused by T. rubrum, T.
interdigitale, and Epidermophyton floccosum in individuals
aged 12 years or more.
• The recommended dosage of 2% sertaconazole cream is
applied once or twice daily for a period of 4 weeks.

40. Various newer topical formulations of sertaconazole,
i.e., anhydrous gel, microsponge, microemulsion,
nanovesicles, loaded hydrogel, bioadhesive gel,
transdermal patch, and nail patch
are under development to enhance the dermal
delivery and skin retention of the drug.

41. • Luliconazole, R-enantiomer of lanoconazole
• It has been found that the MIC for luliconazole is 1–4 times lower than
lanoconazole and terbinafine for T. rubrum and T. mentagrophytes
strains.
• Luliconazole 1% has also been found to successfully eradicate
dermatophytic infection caused by T. mentagrophytes in experimental
model in half the time or less required for 1% terbinafine cream and
bifonazole 1% cream.
• Besides dermatophytes, in-vitro studies have documented the
effectiveness of luliconazole against Candida, Malassezia subspecies,
and Aspergillus fumigatus.
• Luliconazole was approved by the FDA in 2013 for the treatment of
tinea pedis, tinea cruris, and tinea corporis. The recommended dosage
of 1% luliconazole is once daily for 1 week for tinea cruris and tinea
corporis and 2 weeks for tinea pedis over affected area(s) and
immediate surrounding area(s).

42. It has excellent penetration capability
through the nail layer.
A multicenter, double-blind,randomized study using
once daily luliconazole 5% nail solution in cases with
distal lateral subungual onychomycosis with 20–50%
clinical involvement have found good efficacy and
tolerability.

43. • Eberconazole, an imidazole azole, has been found to
have broad antimicrobial activity. It has shown good
efficacy against dermatophytes, Candida, and
Malassezia furfur. Similar to sertaconazole, it also
possesses antibacterial property against Gram-positive
bacteria. It has anti-inflammatory activity similar to
aspirin and this effect has been attributedto the
inhibition of 5-lipooxygenase and to a lesser extent of
cyclooxygenase-2.
• A randomized controlled trial foundthe efficacy and
safety of 1% eberconazole nitrate cream similar to that
of 1% terbinafine hydrochloride cream in the treatment
of localized (<20% involvement) tinea corporis and
tinea cruris.
• Lanoconazole, a racemic imidazole antifungal agent,A
study showed lower efficacy of lanoconazole compared
to terbinafine and luliconazole. Once daily local
application is currently recommended at affected sites.

44. • Efinaconazole is a newer emerging triazole antifungal effective
against dermatophytes, Candida species, and nondermatophyte
molds. Efinaconazole 10% topical solution got FDA approval for
the topical treatment of toenail onychomycosis caused by T.
rubrum and T. mentagrophytes in 2014. It is to be applied once
daily for 48 weeks with the help of a brush applicator to the
affected toenail and its undersurface, nail folds, nail bed, and
hyponychium. Efinaconazole was found to penetrate the nail bed
to a greater extent (14.3% efinaconazole vs 0.7% and 1.9% for
ciclopirox and amorolfine in keratin suspensions, respectively).
• Pramiconazole is a newer triazole under development which has
shown good in-vitro and clinical activity against dermatophytes,
Candida and Malassezia. Both oral as well as topical preparations
of pramiconazole have shown superior efficacy compared to
itraconazole and terbinafine

45. Allylamines
• Allylamines interfere with ergosterol synthesis by
inhibiting the formation of squalene epoxidase,
which is a precursor of lanosterol and involved in
the formation of cell membrane.
• inhibition of this pathway leads to the
accumulation of squalene, which leads to increased
membrane permeability and disruption of cellular
organisation ensuring death of fungus.
• Terbinafine and naftifine are the two important
drugs of this group.

46. • Terbinafine
FDA approved for the treatment of interdigital-type
tinea pedis (athlete’s foot), tinea cruris (jock itch),
and tinea corporis (ringworm).
• a randomized control trial found similar efficacy
and tolerability of 1% terbinafine cream to 1%
eberconazole nitrate cream in the management of
localized tinea corporis and cruris.

47. • Naftifine
• A topical fungicidal allylamine that is effective against
dermatophytes, Candida and Aspergillus species. It is also
effective against Gram-negative and Gram-positive bacteria.
Furthermore, naftifine has anti-inflammatory activity by
targeting prostaglandin pathway.
• Similar to terbinafine, it’s efficacy is similar to azoles.
• Once daily application of naftifine 2% cream and gel for 2
weeks is FDA approved for the treatment of interdigital
tinea pedis, tinea cruris, and tinea corporis caused by the
organism T. rubrum in adults over 18 years of age.
• Use of both the cream and gel formulations shows good
rates of mycologic and clinical cure after 2–8 weeks of use

48. Oxaboroles
• Blocks protein synthesis via the inhibition of
leucylaminoacyl transfer RNA (t-RNA) synthetase.
• Premature termination of protein synthesis leads to
growth inhibition and death of the fungus.
• It has broad-spectrum antifungal activity including
dermatophytes, such as T. rubrum and T.mentagrophytes,
C. albicans, and nondermatophytic moulds.

49. Tavaborole
• Tavaborole, the first oxaborole, was approved by the
FDA in July 2014 as a topical treatment of toenail
onychomycosis.
• Tavaborole has low-molecular-weight leading to
increased penetration through full-thickness human
nail plates.
• 5% tavaborole solution has superior penetration
capabilitycompared to 8% ciclopirox solution
• Once daily application is recommended for 48 weeks
• Mycologic cure rate of tavaborole is lower than oral
antifungal agents (30–36% vs 50–76%, respectively)

50. Hydroxypyridones
• Hydroxypyridones are weak acids and show broad-spectrum
antimicrobial activity.
• They act by chelating trivalent metal cations causing inhibition of
metal-dependent enzymes leading to less degradation of
cytoplasmic peroxides, increased sensitivity of cells to oxidative
stress, and decreased levels of iron permeases or transporters.
This multilevel mechanism of action is responsible for very low
incidence of resistance.
• Ciclopirox is a prototype drug of this group. Rilopiroxand
octopirox are other recently described drugs of this group.
• An RCT comparing P-3051 formulation (water-soluble ciclopirox
8% formulation in hydroxypropyl chitosan) to amorolfine 5%
lacquer in the treatment of mild-to-moderate toenail
onychomycosis found statistical superiority of P-3051 over
amorolfine after 48 weeks in treatment success.

51. Morpholines
• Morpholines inhibit two enzymes, i.e., C-14 sterol
reductase and C-8 sterol isomerase, in the
ergosterol synthesis pathway.
• Amorolfine is the most commonly used drug of this
group. It has been primarily used for the
management of onychomycosis in lacquer
formulation.
• Efficacy and safety of amorolfine cream have been
found to be comparable to various azoles.

52. Photodynamic therapy
• Photodynamic therapy (PDT) involves the systemic or
topical application of a photosensitizing agent followed
by the selective illumination of the target lesion with
light of an appropriate wavelength which leads to
generation of free radicals and subsequent cell death.
• Aminolevulinic acid and methylene blue are the most
commonly used photosensitizing agents for PDT.
• In a recently conducted RCT, PDT using methylene blue
as photosensitizing agent was found to have
significantly superior efficacy over weekly 300 mg of
oral fluconazole.

53. Lasers
• The exact mechanism of action of lasers in treating
onychomycosis is not known
• but proposed mechanism includes heat
disintegration of fungal elements. Temperature
exceeding 50°C leads to direct thermal killing.
• Nd: YAG 1064 nm laser is the most commonly used

54. Future prospects
A recently developed novelantifungal drug,
ME1111, fulfils the characteristics of
• an ideal antifungal drug for onychomycosis
• it has potent antidermatophyte activity,
• low molecular weight leading to increased penetration, and
• maintaining good inhibitory activity even in the presence of keratin.
• It primarily acts by the inhibition of succinate dehydrogenase
(complex II), a critical enzyme involved in electron
transport chain in mitochondria.
• AR12 (OSU-03012) is
an acetyl CoA synthase inhibitor which is in phase 1 trials
for malignancy but has also been found to have action on
onychomycosis.

56. Income, and Quality of Life
in Psoriasis: A Study from
South India

57. Introduction
• Psoriasis is a chronic, systemic disease with a
multifactorial etiology that affects 1–3% of the global
population
• Psoriasis results in a high cost for the society and the
patient for clinical examination, laboratory
examination, treatment, as well as the loss of career
productivity.
• Hence, this study was structured to evaluate the effect
of psoriasis on an individual physically, mentally,
emotionally, and economically.

58. Materials and Methods
• Justice KS Hegde Hospital attached to KS Hegde
Medical Academy, Mangalore
• 102 patients from Oct 2015 to march 2017

59. A. Psoriasis Area and Severity Index (PASI), dermatology life quality
index (DLQI) & monthly family income were used in this study.PASI
was calculated by scoring the lesion for erythema, induration, and
desquamation & the area of the body affected by psoriasis.PASI
score was graded as mild, moderate, and severe with scores of <5,
5–10, and >10, respectively.
B. The questionnaire proposed by Finlay et al. was used to assess DLQI.
Higher score of DLQI indicates greater impairment of QoL.
C. Modified Kuppuswamy’s socioeconomic scale, which uses monthly
family income to assess financial status, was used.Family income
was calculated by adding the monthly income of all the earning
members of the family for a month.

60. Statistical analysis
• IBM SPSS Statistics,version 22 was used.
• Mann–Whitney U-test: For comparison of the PASI, DLQI
• Spearman’s correlation test: To test the correlation
between the study variables.
• Multiple linear regression: To identify the predictor
variables of DLQI.
• P value of <0.05 was considered statistically significant.

61. RESULTS
• 102 patients with psoriasis were included.
• Male-to-female ratio 3:1.
• Age range 18-65 years & 38.2% of the patients > 51 years.
 Mean age was 44 ± 12.31 years.
• Duration of psoriasis: ≤1 year in 17 (16.7%),
1–5 years in 61 (59.8%), and
≥5 years in 24 (23.5%).
 Mean duration of the disease was 5.16 ± 6.42 years.
 23.5% of the patients had disease> 5 years.
• The most common type of psoriasis was chronic plaque psoriasis (85.3%) followed by localized
scalp psoriasis (11.8%).
 Inverse psoriasis (1%)

62. • Mean PASI score was 8.20 ± 6.18.
• Mean DLQI was 13.01 ± 6.95,
• Mean family income was INR 15570.10 ± INR 10081.82
per month.
• 25.5% patients were unemployed.
• 47.1% belonged to upper middle class according to the
modified Kuppuswamy’s socioeconomic scale.

63. • The disease severity assessed using PASI score
correlated significantly with DLQI (r = 0.815, P = 0.001).
Higher the PASI score greater the DLQI, and hence,
greater is the impairment of QoL
• Family income was also found to have significant
negative correlation with DLQI (r = −0.375, P = 0.001),
with lower income group having higher DLQI and
greater impairment of QoL
• Significant negative correlation between disease
severity (PASI) and family income (r = −0.323, P =
0.001).

64. • Psoriasis can lead to loss of productivity and severely affect the finances
of the family.
This study, using multiple linear regression found that QoL had a
significant negative association with family income.
• QoL also had a significant association with disease severity.
• Psoriasis and the cost of treatment affect an individual, both physically
and psychologically. Severity of psoriasis has a negative impact on QoL
and family income. It may also lead to higher cigarette smoking and
alcohol consumption which adds to the economic burden
.
• Psoriasis can also be aggravated by the stress associated with low
financial status as well leading to a self-enhancing vicious cycle.

65. Limitations:
• The study sample cannot be considered representative of general population
because it is a single hospital-based study.
• study design also lacks a control group; it is unknown whether healthy
individuals of similar age have better QOL, and hence, comparison of these
cases with healthy individuals is not possible.
• As psoriasis is a chronic disease with a fluctuating course, for effective
treatment, QoL, loss of productivity, disease severity, and the interplay between
them plays a major role.
• The observations in this study provide an insight on these factors, which has a
significant impact on the life of psoriasis patient.
• Hence, it is advisable to consider the economic status of the patient while
choosing the therapeutic option for psoriasis management.

66. DISCUSSION
• Psoriasis affects patient’s life massively.
• Psychological stress is also a well-known trigger in psoriasis. It
forms the cause or a maintaining factor in the expression of the
disease in psoriasis patients.
• Farber et al., 40% of the patients reported psoriasis at the time of
worry and approximately 37% had worsening of disease
associated with worrying.80% of the psoriasis patients
complained of stress-related flare of the disease.
• There is decreased patient compliance and treatment efficacy in
patients with comorbid psychological stress.

67. • QoL measurement gives an insight about the psychological status of
an individual. DLQI can act as a reference score, which can be useful
in determining the change in QoL before, during, and after
treatment due to significant psychological and physical risk in
psoriasis.
• This study showed that psoriasis affects DLQI and that the
impairment of QoL is directly proportional to the severity of psoriasis
measured by PASI. The lowering in DLQI following decrease in PASI
denotes the psychosocial wellbeing of the patient following
remission or treatment.