ADDIS ABEBA UNIVERSITYCOLLEGE OF HEALTH SCIENCE

DEPARTMENT OF DERMATOVENEROLOGY

A research paper on prospective study on magnitude of metabolic syndrome in

psoriasis patients in alert center from May 2022-Sept 2022

By:Dr. Tsigereda abera (MD, Dermatovenereology Resident)

Advisors:Dr. Amel Beshir, (MD, Ass. Prof in Dermatovenereology)
&
Dr. Edom Mulubirhan (MD, Ass. Prof in Dermatovenereology)

A Research paper submitted to the department of Dermatovenereology, Addis

Ababa University, in Partial Fulfillment of the Requirements for the Specialty
Degree in Dermatovenereology

Addis Ababa, Ethiopia

September, 2022

Acknowledgement
First, I would like to thank AAU, Dermatovenorology department for giving me
the chance to do this research paper which will have significant value to my future
career.
Next my deepest gratitude goes for my advisors Dr. Amel Beshir & Dr. Edom
Mulubirhan for their valuable advice & comments while doing this paper.
Finally, I would like to extend my special thanks to dermatovenorology residents
and all those who have helped in carrying out the research.

Contents
Abbreviations/ Acronyms.....................................................................................vii
Abstract.................................................................................................................viii
1. Introduction.....................................................................................................10
1.1. Background...............................................................................................10
1.2. Statement of the problem.........................................................................13
1.3. Significance of the study...........................................................................14
2. Literature review.............................................................................................15
3. Objective of the study.....................................................................................22
3.1. General objective......................................................................................22
3.2. Specific objectives.....................................................................................22
4. Methods and Materials...................................................................................23
4.1. Study area..................................................................................................23
4.2. Study period..............................................................................................23
4.3. Source population.....................................................................................23
4.4. Study population.......................................................................................23
4.5. Study design...............................................................................................24
4.6. Eligibility criteria......................................................................................24
4.6.1. Inclusion criteria.................................................................................24
4.6.2. Exclusion criteria................................................................................24
4.7. Sample size determination and sampling technique..............................24
4.8. Study variables..........................................................................................24
4.8.1. Dependent variable.............................................................................24
4.8.2. Independent variables........................................................................24
4.9. Operational definitions.............................................................................24
4.10. Data collection tools and procedures...................................................25
4.11. Data processing and analysis................................................................25
4.12. Data quality management.....................................................................25
 4.13. Ethical considerations...........................................................................26
4.14. Data dissemination and utilization.......................................................26
5. Result................................................................................................................27
6. Discussion.........................................................................................................38
7. Limitations of the study..................................................................................41
8. Conclusion........................................................................................................42
9. Recommendation.............................................................................................43
10. References........................................................................................................44
Annexes...................................................................................................................48
Annex I.................................................................................................................48
List of figures
Figure 1:- Magnitude of MetS in each clinical type psoriasis patients in …28

Figure 2: Magnitude of MetS in each clinical type psoriasis patients at

ALERT/AHRI........................................................................................................29

Figure 3 Proportion of patients with psoriasis get hypertension, increased

FBS, Abdominal obesity, low HDL, and High TGA at
ALERT/AHRI……………..32

Figure 4: Proportion of patients with metabolic syndrome get hypertension,

increased FBS, Abdominal obesity, low HDL, and High TGA in psoriasis
patients……………33

Figure 5: Magnitude of MetS in psoriasis patients in at

ALERT/AHRI……….36
List of tables
Table 1 Table1:- Socio-demographic characteristics of psoriasis patients in
ALERT/AHRI…27

Table 2 Table 2:- Socio-demographic characteristics of patients with

metabolic syndrome patients in ALERT/AHRI….

Table 3:- Chi-square test of association with MetS patients in alert

center…………...
Abbreviations/ Acronyms
AAU - Addis Ababa University

AHRI – Armauer Hansen Research Institute

ALERT - All African Leprosy Rehabilitation Training Center

E.C. – Ethiopian calendar
FMoH - Federal Ministry of Health
G.C. – Gregorian calendar
OPD – Out Patient Department
SPSS - Statistical Package for Social Science

mets-metabolic syndrome
Abstract
Background
Psoriasis is a chronic inflammatory and immune-mediated disease associated with
several comorbidities, such as obesity, hypertension, diabetes mellitus,
dyslipidemia and cardiovascular disorder. The early recognition and assessment of
these comorbidities and selecting appropriate treatments for psoriasis, and giving
the correct recommendations.
Objective
The aim of this study was to assess the magnitude of metabolic disorder among
psoriasis patients visiting alert center dermatovenorology clinic.
Methodology
Cross-sectional prospective study was conducted at alert dermatovenereology
clinic over 4 month .metabolic syndrome was defined using the revised
harmonized criteria (IDF) for metabolic syndrome & severity was measured via
body surface area involved
Result: - Out of a total of 160 psoriasis patients during the study period , 82
patients (51.2%) are male and 78 patients (48.2%) are female. Hospital magnitude
of metabolic syndrome was found to be 23.8% and there was a slight female
predominance with 21 (55.3%). the magnitude of component of metabolic
syndrome was hypertension (23.8%), raised FBS(29.4%),low HDL(26.9%),high
TGA(33.1%)and abdominal obesity (40%).there is statically significant
association of mets with age group 30-39(AOR=0.26AND P-value=0.004) ,40-49
(AOR=0.02 & P-Value =0.001)50-59(AOR=0.205 &P value =0.002), BSA
involvement >10 % (AOR=0.135, P-value =0.023), marriage status of married
(AOR=0.029 P-value =0.036), divorced (AOR=0.059, P-value =0.039), those who
are alcoholic (AOR=9.472, P-value 0.034)
Conclusion: - Psoriasis patients should be informed about the potential metabolic
risks and receive therapies for behavioral changes besides anti-psoriatic treatment
in order to decrease these risks

Key words: -psoriasis, metabolic syndrome

1. Introduction
1.1 Background
Worldwide 125 million people have psoriasis (3). Psoriasis affects men and
women equally, and is seen in all races. Although psoriasis can begin at any age,
there seem to be two peaks in onset: one between ages 20 and 30 and another
between 50 and 60. (16)
Clinical features of psoriasis vary in morphology, extent of disease, duration,
periodicity of flares, and response to therapy. The most common morphology is
inflamed, edematous skin plaques, and coalescing papules covered with silvery
white scales (6)
The characteristic redness and edema of inflammation are more obvious in white
skinned persons, whereas in blacks, it is less conspicuous or absent.
The clinical types include plaque psoriasis, guttate psoriasis, pustular psoriasis,
erythrodermic psoriasis, scalp psoriasis, nail psoriasis, and psoriatic arthritis. (8
A survey by the National Psoriasis Foundation in USA found that 75% of patients
with psoriasis reported a moderate to large negative impact of the disease on the
quality of their life, with an alteration of everyday activities. (28)
The negative impact of psoriasis may not be limited to its cutaneous or
psychosocial manifestations. Previous studies have suggested a link between
psoriasis, a common inflammatory disorder, and individual components of the
metabolic syndrome, such as obesity, hypertension, diabetes, and dyslipidemia (28)
Psoriasis is a prototypical Th-1 inflammatory disease characterized by expansion
and activation of Th-1 T cells, antigen presenting cells, and Th-1 cytokines.
Specifically, chronic inflammation in Psoriasis leads to increased insulin-like
growth factor-II (IGF-II) in the skin and blood of Psoriasis patients.(30,33,10)
IGF-II promotes epidermal proliferation and is also implicated in promoting
atherosclerosis, in modulating body fat mass and lipid metabolism. Circulating
levels of Th-1 cytokines, adhesion molecules such as ICAM-1 and E-selectin, and
angiogenic factors, such as vascular endothelial growth factor (VEG-F) are
elevated in Psoriasis, obesity, and coronary artery disease.(38)
Chronic inflammation can also lead to dysfunction in a variety of organ systems.
Th-1 inflammatory cytokines such as TNF-α are elevated in the skin and blood of
patients with Psoriasis and are critical to recruiting T cells to the skin and joints,
promoting angiogenesis, and epidermal hyper-proliferation. Similarly, TNF-α is
secreted in adipose tissue and is an important feature of the chronic low-level
inflammation seen in obesity& insulin resistance. (6)
Psoriasis is belived to be associated with different comorbidities like metabolic
syndrome, autoimmune disorders ,uveitis ,erectile dysfunction, psoriatic
arthritis ,etc. Michado and pinto stated that 73% psoriasis patients have at least one
comorbidities. (30)
march. Psoriasis causes not only
skin inflammation but also systemic
inflammation, leading to increased insulin
resistance, vascular endothelial damage,
atherosclerosis, and myocardial infarction.
This sequence of events is known as the
psoriatic march. Obesity is an aggravating
factor in this process, and continuous
systemic treatment is a suppressiMetabolic syndrome (MetS) is a cluster of
cardiovascular risk factors, including glucose intolerance or
insulinresistance,dyslipidemia,hypertension,and central obesity .(6).
MetS is also associated with greater cardiovascular risk and is a predictor of
cardiovascular disease, diabetes, and stroke . There is strong evidence showing an
association between MetS and psoriasis.( 7 )
1.2 Statement of problem
Even though psoriasis was considered to be confined to the skin until recently, it is
now accepted as a chronic inflammatory disease with systemic manifestations
mirroring those of other autoimmune diseases
This notorious, non- contagious, immune mediated, chronic inflammatory disorder
having deep psychological, social impacts and associated with an increased
cardiovascular risk.
Previous studies have suggested a link between psoriasis, a common inflammatory
disorder, and individual components of the metabolic syndrome, such as obesity,
hypertension, diabetes, and dyslipidemia

In particular, the prevalence of MetS in patients with psoriasis ranges from 20 to

50%, with a risk of having MetS that is at least double in psoriatic patients
compared to non-psoriatic control individuals. (18).
recently psoriasis may confer an independent risk of myocardial infarction
especially in young patients.
Recent research reported an association between psoriasis and metabolic disorders
such as obesity, dyslipidemia, and type II DM and it is shown that severe psoriasis
might be associated with increased mortality rate due to cardiovascular disorder
The broad literature linking psoriasis to metabolic disorders has led to changes in
standard of care recommendations for patients with psoriasis. In particular,
practitioners are encouraged to screen psoriasis patients, especially when disease is
severe, for metabolic disorders and cardiovascular risk factors and institute
appropriate prevention strategies.
Despite Psoriasis is increasing in magnitude with co-morbidities of metabolic
syndrome disease in an alarming rate nationally and globally, there are few studies
done in Africa. The magnitude of metabolic syndrome among psoriasis patients
visiting health institutions Is not well known” in Ethiopia and also patients are in
adequately investigated and followed for the subsequent development of metabolic
disorder.

1.3 Significance of this study

This study will provide necessary information regarding how prevalent is
metabolic syndrome both to the patient and clinician. AS a result, the clinician will
design better treatment modalities, improve the standard care of patients with early
recognition and assessment of these comorbidities, and improve the quality of life
of the patient based on the current generated knowledge.
It will also alert the policy makers, clinicians and patients to avail instruments and
to take protective measures associated with metabolic disorder. In addition this
study will also provide base line information for the future studies regarding this
topic.
2. Literature Review
The worldwide prevalence of MetS has steadily risen over the years, hand-in-hand
with the development of industrialization and globalization. MetS have been
currently estimated to affect approximately 20-50% of the psoriatic population and
is associated with an increased risk of morbidity and mortality that is two to three
times higher compared to healthy subjects in IDF criteria (2020). However, there
are some literatures in different parts of the world studying the prevalence of MetS
in psoriasis patients.
2.1 India
Case control study in 2010 by Nisa N, Qazi MA. on prevalence of metabolic
syndrome in patients with psoriasis was under taken. the study found that the
prevalence of mets inpsoriasis patient was significant42(28%)as compare with
control9(6%) odds ratio (OR) = 6.09, P<0.05. Psoriatic patients also had a
significantly higher prevalence of hypertriglyceridemia (73/150 among cases vs
24/150 among controls; P<0.05), arterial hypertension (74/150 among cases vs
24/150 among controls; P<0.05) and impaired fasting plasma glucose levels
(27/150 among cases vs 04/150 among controls; P<0.05). Psoriatic patients with
metabolic syndrome had mean disease duration of 13.67±11.87 years against
6.46±5.80 years in those without metabolic syndrome.
In 2016, another Hospital Based Case-Control Study in india by Praveen Kumar,
U.Ganguly et,al on Prevalence of Metabolic Syndrome in Psoriasis Patients and its
Relation to Disease Duration was done .the study found that Metabolic syndrome
was more common in psoriatic patients than in controls but the difference was
statistically insignificant (60% vs. 40%, p-value=0.12). The psoriasis group had a
higher prevalence of elevated blood glucose levels and higher waist circumference
compared to controls. Psoriasis patients had a higher prevalence of high
triglyceride levels than controls, the difference being statistically insignificant
(40% vs. 30%, p-value = 0.41).
The prevalence of low HDL levels was significantly higher in cases compared to
controls (86.7% vs. 60%, p-value = 0.02). There was no relation between presence
of metabolic syndrome and duration of psoriasis.

2.2 Turkey
Hospital case control study done in turkey in 2011 by Zindancı, I., et,al found that
Compared to the control group, metabolic syndrome, diabetes mellitus, and
hypertension were found to be higher in psoriasis patients.Metabolic syndrome was
increased by 3-folds in psoriasis patients and was more prevalent in women than in
men.It was determined that the prevalence of metabolic syndrome was higher in
psoriasis patients after the age of 40. Metabolic syndrome was not related to
smoking, severity of psoriasis, and duration of disease.The influence of female
gender and age on the occurrence of MS in psoriasis patients was found significant
(P<0.01). Female gender increased the risk of MetS by 3.195-fold (95% CI: 1.12–
9.04) compared to males; patients aged between 40–49 had an increased risk of
MetS by 5.141-fold (95%CI: 1.75–24.47), patients aged over 60 had an increased
risk of MetS by 6.531-fold (95% CI: 1.55– 3.37). It was found that MetS was
independent from smoking habit
another study done by Adışen,et,al.(2018) in turkey on 563 individual adult
patient was done the study found that metabolic syndrome was found in 12.6% of
the patients [central obesity (38.7%), hypertension (14.3%), dyslipidemia (18.6%),
and diabetes (9.2%)], while 50.3% had smoking, and 3.3% had alcohol
consumption. Patients with metabolic syndrome were older and more likely to
have a longer disease duration than those without metabolic syndrome (p<0.05 for
each).
The prevalence of metabolic syndrome was higher in women than in men.
Psoriasis was more severe in patients with central obesity, diabetes and smoking
than in those without (p<0.05 for each).
2.3 Afghanistan
A Case– Control Study done by Ahmad Khalid Aalemi, in 2021
In total, 51.8% of the cases and 44.7% of the controls were male. The average age
of participants was 33.4±13.1 years in the case group and 41.1±15.4 years in the
control group. The prevalence of metabolic syndrome was higher among patients
with psoriasis compared to controls (36.8% vs 21.1%) with OR of 2.18 (p=0.009).

The average duration of disease for psoriasis was 4.2 years with 5.6 years SD. The
average PASI was 10.8 with 5.1 SD. More than half of the cases (62.3%) had
moderate to severe psoriasis and 37.7% had mild psoriasis. In addition,
overweight/obesity was more prevalent among cases compared to controls (65.8%
vs 41.2%) with OR of 2.74 (p<0.001), whereas the waist circumference was not
significantly different between the two groups.
2.4 Lebanon
Salam Itani et,al. in 2020 done a study on the prevalence of metabolic syndrome
in patients with psoriasis in Lebanon. the study found that metabolic syndrome
prevalence was 35.3% .which implies patients with psoriasis were two times more
likely to have metabolic syndrome with an odds ratio (OR) of 2.4 .all components
of MBS were more prevalent in psoriasis patients than in controls. PASI score was
greater in patients with MBS than those without MBS (10.5 11.5 vs. 7.0 8.1, P =
0.05). MBS prevalence tended to be higher in the inverse type than in others
(52.2% versus 32.3%; P = 0.06) and in patients with nail pitting versus those
without (45.3% vs. 28.2%; P = 0.03).
2.5 In China
cross-sectional study was undertaken in 2018 by by Xin-Yu Gui, Xiao-Ling
Yu,et al on Prevalence of metabolic syndrome on A total of 859 psoriasis
patients and 1,718 controls patients .the study found that metabolic syndrome
occurred in 14.3% of the psoriasis patients as opposed to 10.0% of the control
participants (P = 0.001).Psoriasis patients had a higher prevalence of
overweight/obesity, hyperglycemia and dyslipidemia when compared with
controls. Meanwhile, psoriasis patients with metabolic syndrome were older, and
had an older age of onset and a longer disease duration when compared with those
without metabolic syndrome.
2.6 In Singapore
A cross-sectional study in Singapore done by waiman,etal. In 2020 Among 338
patients with psoriasis, there were 238 (70.4%) men and 100 (29.6%) women, who
were Chinese (n = 228; 67.5%), Malay (n = 52; 15.4%) and Indian (n = 58;
17.2%). The prevalence of MetS was 45.1%. MetS was 44% more prevalent in
patients older than 50 years (p = 0.02). Malay patients with psoriasis were
significantly more likely to have hypertriglyceridaemia, elevated fasting plasma
glucose and abdominal obesity. There was no significant correlation between
psoriasis severity and risk of MetS.
2.7 Italy
Gisondi, P., Tessari, et,al (2020).done case control study on Prevalence of
metabolic syndrome in patients with psoriasis. The study found metabolic
syndrome .Metabolic syndrome was significantly more common in psoriatic
patients than in controls (30.1% vs. 20.6%, odds ratio 1.65, 95% confidence
interval 1.16–2.35; P=0.005) after the age of 40 years.
Psoriatic patients also had a higher prevalence of hypertriglyceridemia and
abdominal obesity, whereas hyperglycemia, arterial hypertension and high-density
lipoprotein cholesterol plasma levels were similar.
Although psoriasis patients were more frequently smokers, the association of
psoriasis with metabolic syndrome was independent from smoking. There was no
correlation between severity of psoriasis and prevalence of metabolic syndrome.
Psoriatic patients with metabolic syndrome were older and had a longer disease
duration compared with psoriatic patients without metabolic syndrome.
Another Cross-Sectional Study done by Parodi, A et, al. (2014). in A total of 720
patients were enrolled (n = 360 per group) found that the prevalence of MetS was
26.84 % in the psoriatic population and 15.16 % in the control population.

2.8 Serbia
In 2016 hospital based cross-sectional study was done by Milčić D, Janković
S,et,al on the prevalence of metabolic syndrome in psoriasis patients .the study
found metabolic syndrome prevalence was 45.1% with control group19.1%and

All the components of MetS, except low level of HDL-C, were significantly higher
in psoriatic group compared with controls: abdominal obesity (46.7% vs. 26.4%),
raised triglyceride levels (38.1% vs. 24.5), high blood pressure (67.2% vs. 25.8),
and raised glucose or type 2 DM (31.6% vs.13.5). and also They failed to find any
statistically significant association between the metabolic syndrome and clinical

severity of psoriasis.

2.8 In United Kingdom

In 2012 population based study was conducted by, Sine ´ad M. Langan1,2, Nicole
M. Seminara , regarding prevalence of metabolic syndrome on psoriasis patients
with A total of 44,715 individuals 4,065 with psoriasis and 40,650 controls. In all,
2,044 participants had mild psoriasis (p2% body surface area (BSA)), 1,377 had
moderate psoriasis (3–10% BSA), and 475 had severe psoriasis (410% BSA).
Psoriasis is associated with metabolic syndrome and the association increases with
increasing disease severity. Furthermore, associations with obesity,
hypertriglyceridemia, and hyperglycemia increase with increasing disease severity
independently of other metabolic syndrome components

2.9 brazil
In 2017, case control study was done by Thelma Skare Rua Padre Anchieta,on
prevalence of metabolic syndrome .the study found that the prevalence of
metabolic syndrome was 49.4 %with control of 35% and Patients with psoriasis
had higher body mass index (p=0.02), higher systolic blood pressure (p=0.007),
lower HDL cholesterol (p=0.01), higher glucose (p=0.04), higher waist
circumference (p=0.003) and more angina pectoris (p=0.03;OR=2.5; 95% CI=1.04-
6.15) than controls. When psoriasis with and without MS were compared, those
with MS were older (p=0.0004), had disease onset at older age (p=0.02), more
tobacco exposure (p=0.02), and a tendency to have less scalp involvement age and
scalp involvement were independently associated with MS in the psoriasis sample.
2.10 In America
In 2003-2006 national nutritional and health survey done by Love TJ, Qureshi
AA,et,al on the prevalence of metabolic syndrome was found that The prevalence
of the metabolic syndrome was 40% among psoriasis cases and 23% among
controls. The most common feature of the metabolic syndrome among patients
with psoriasis was abdominal obesity, followed by hypertriglyceridemia and low
levels of high-density lipoprotein cholesterol.
.
2.11 In South African
In 2005 Population based study done in cape town ,south Africa by Peer N,
Lombard C, Steyn K, Levitt N on 1099 participants prevalence of metabolic
syndrome was 30.7% (95% confidence interval (CI): 27.4–34.1) and 31.7% (95%
CI: 28.4–35.3), respectively, with higher rates among women (43.5%, 95% CI:
39.2–47.9 and 44.9%, 95% CI: 40.5–49.3) than men. Overall, metabolic syndrome
components that were higher in women compared with men were central obesity
(86.0% vs. 20.1%) and low high-density lipoprotein cholesterol (75.0% vs. 33.4%)
while in men, raised blood pressure (51.4%) was the most frequent.{44}
In the multiple logistic models, higher age (55–64 years (peak age) versus 25–34
years: odds ratio (OR): 7.35, 95% CI: 3.27–16.56, p<0.001) and wealth (highest
versus lowest: OR: 1.87, 95% CI: 1.14–3.08, p¼0.014) in women, and higher age
(p¼0.002) and employment compared with unemployment (OR: 3.01, 95% CI:
1.18–7.67, p¼0.021) in men were significantly associated with metabolic
syndrome.{42}
Another case control study done by Nasirin G.et,alin 2018 at Johannesburg The
prevalence of metabolic syndrome (MetS) (52.4% vs. 33.7%; P = 0.007), type 2
diabetes (T2D) (25.2% vs. 4.1%; P < 0.0001), and hypertension (70.9% vs. 46.6%;
P = 0.001) were all higher in the psoriasis group. High-sensitivity CRP was higher
in psoriasis patients than controls (4.70 (2.00, 10.9) vs. 2.00 (1.10, 4.80) ng/ml; P <
0.0005). Multivariable logistic regression analysis showed that severe psoriasis
was independently associated with MetS (odds ratio [95% CIs]: 4.42 [1.72, 11.4];
P = 0.002), T2D (11.3 [3.07, 41.3]; P = 0.0002), and hypertension {23}

2.12 In Tunisia
In 2011, a case control study was conducted by a mebazaa,melasmi,et,al on
metabolic syndrome prevalence and determinants in psoriatic patients .the study
find that the prevalence of mets was higher in psoriatic individual than
control(35.5%vs 30.8%) . (36)
3 Objective of the study
3.1 General objective
 To assess magnitude of metabolic syndrome among psoriasis patients
visiting alert center dermatovenerology clinic, Addis Ababa, Ethiopia,
3.2 Specific objectives
 To assess magnitude of hypertension among psoriasis patients visiting alert
center dermatovenereology clinic, Addis Ababa, Ethiopia
 To assess magnitude of central obesity among psoriasis patients visiting alert
center dermatovenereology clinic, Addis Ababa, Ethiopia
 To assess magnitude of impaired fasting glucose among psoriasis patients
visiting alert center dermatovenerology clinic, Addis Ababa, Ethiopia,
 To asses association of behavioral risk with metabolic syndrome among
psoriasis patients visiting alert center dermatovenerology clinic, Addis
Ababa, Ethiopia,
4 Methods and Material
4.1 Study area
The study was conducted at All African Leprosy Rehabilitation Training Center
(ALERT). ALERT was established in 1932 by a philanthropist as a treatment
center for leprosy. The hospital is one of the largest government hospitals in the
capital, reaching for millions of people from different parts of the country. This
center is located in an area called Zenebework, Kolfe Keraniyo subcity of Addis
Ababa. It is also a training and research center in areas such as tuberculosis,
HIV/AIDS, leprosy, leishmaniasis and other tropical diseases. The hospital covers
a range of clinical services including Internal Medicine, Dermatology,
Ophthalmology, Orthopedics, General Surgery, Plastic and Reconstructive Surgery
Departments.
4.2 Study design

A hospital based, prospective, cross-sectional Study was employed to assess the

magnitude of metabolic syndrome in patient with psoriasis visiting Dermatology
unit of ALERT Hospital, Addis Ababa, Ethiopia.
4.3 Study period
The study period was from May 2022- September 2022
4.4 Source Population
All psoriasis patients visiting dermatologic clinic alert center
4.5 Study population
All psoriasis patients visiting dermatologic clinic alert center in the study period
4.6 Eligibility criteria
4.6.1 Inclusion criteria
 Age group 18 years and above.
 Clinical diagnosis of psoriasis
4.6.2 Exclusion Criteria
 Pregnant women
4.7 Study variables
4.7.1 Dependent variable
 Prevalence of metabolic disorder
4.7.1 Independent variables
 Sex
 age
 occupation,
 religion,
 educational status,
 smoking status
 marital status
 disease severity & duration of psoriasis

4.8 Data collection tools and procedures

This study included 160 adult psoriasis patient visited alert dermatologic clinic in
the study period. short structured questionnaire was used to collect data regarding
age, sex, education status, working & marriage status, income ,residence and
duration of illness ,smoking and drinking status and clinical type of psoriasis
Smoking and drinking status were categorized as never, current/former. And
person who smoke more than 20 pack per year categorized as heavy smoker for
men, consuming more than 4 drinks on any day or more than 14 drinks per week
for women, consuming more than 3 drinks on any day or more than 7 drinks per
week defines heavy drinking.
for assessment of psoriasis severity body surface area were used. psoriasis was
considered mild if BSA < 5%, moderate 5-10% as it is localized and sever and
extensive BSA > 10 % of involvement.
Anthropometric measures recorded in this study were weight, height, waist
circumference and blood pressure. Weight and height measure were assessed using
standard weight balance with height measurement in kg and meter respectively
Waist circumference was measured by measuring tape putting horizontally
around the abdomen at the level of hip bone ,blood pressure was measured with
manual bp cuff after the subject has been sitting for 5 minute .
FBS, TGA, HDL level were measure using standard biochemistry procedure and
taking venous blood sample from patient who had fasted over night for at least 8 hr
Metabolic syndrome was defined by using harmonized metabolic syndrome criteria
(IDF) CRITERIA
Participant with 3 of more of the criteria :-waist circumference to define
abdominal obesity in African origin for men ≥94 cm and for women ≥80
cm ,TGA ≥150 MG /DL ,HDL for male ≤40 mg/dl for women ≤50 mg /dl ,BP
systolic/diastolic =≥130/85or hx of hypertension ,FBS >100 mg /dl
4.9 Operational definition
Psoriasis patients
Patient who is diagnosed to have psoriasis by dermatology seniors and
dermatologic residents at alert hospital
Metabolic Syndrome
The criteria for diagnosis of metabolic syndrome were those recommended by
IDF(harmonized )criteria which is defined by the presence of at least three of the
following components:
1. Waist circumference ≥94 cm in African males and ≥80 cm in African
females;
2. Serum triglycerides ≥150 mg/dl (or on treatment for raised triglycerides);
3. HDL cholesterol <40 mg/dL in males and <50 mg/dL in females (or on
treatment for reduced HDL-c)
4. Blood pressure: systolic ≥130 and/or diastolic ≥85 mmHg (or on treatment
for hypertension);
5. Fasting glucose ≥100 mg/dL (or on treatment for increased blood glucose).
 4.11 Data processing and analysis
Data entering, coding and cleaning was performed and statistical analysis was done
using SPSS (Statistical Package for Social science) version 26. Frequency
distributions percentages, tables , charts were used to show descriptive results and
chi-square & binary logistic regression was used to asses association between
variables . Finally, the study finding was presented using diagrams, tables and
figures.

4.12 Data quality management

A pretested data extraction sheet was used. Trained data collectors were involved
in data collection. The principal investigator closely supervised and actively
participated in the data collection process. Data was checked for completeness,
clarity and consistency after being filled each day.

4.13 Ethical considerations

Prior to starting the research, Ethical Clearance was obtained from Institutional
Review Board (IRB) of Addis Ababa University. Permission to review patient
charts and histopathologic records and Ethical clearance was also obtained from
AHRI/AHRI Ethical Review Committee. Any identifying information of the
patients was not taken. The data collected was not disclosed and remained
confidential as it was only passed between the investigators listed on this protocol.

4.13. Data Dissemination and utilization

The findings of the study will be submitted to AAU, Department of

Dermatovenereology and FMoH. It will also be submitted to scientific journals for
possible publication.
5 Result
5.1Socio-demographic Data
Among 160 psoriasis patients, 82 patients (51.2%) are male and 78 patients
(48.2%) are female. The peak occurrence age of psoriasis is within the 5th decade,
which measures 34.4% (55 patients) of psoriasis patients and the second highest
occurrence age of psoriasis is in the 4th decade time paired, which is 20% (40
patients) out of the population. Among the study participants, 80% (128 patients)
of psoriasis patients are from urban areas, and the other 20% (34 patients) of
the patients are from rural areas.
The majority of psoriasis patients have experience skin lesion conditions over 2-5
years’ time intervals, which accounts for 28.1% (45 patients) of the psoriasis
patients. The majority of psoriasis patients, which measures 28.1 % (45 patients)
out of the study participants have experienced skin lesion conditions for 2-5 years’
time interval and followed by 26.3% (42 patients) of psoriasis patients who
experienced skin lesion for11-15 yrs.
Table1:- Socio-demographic characteristics and clinical profile of psoriasis patients in alert
center, Addis Ababa, Ethiopia.
 Variable ` Frequency Percentage
18-29 33 20.6
30-39 40 25.0
Age 40-49 55 34.4
50-59 12 7.5
60+ 20 12.5
Male 82 51.3
Sex
Female 78 48.8
Urban 128 80.0
residency
Rural 32 20.0
primary school 52 32.5
secondary school 49 30.6
Vocational (TVET) Level III
Education 17 10.6
status Diploma
Tertiary 19 11.9
No formal education 23 14.4
government worker 33 20.6
Farmer 16 10.0
working status private worker 55 34.4
on pension 9 5.6
other 47 29.4
Plague 144 90

Psoriasis Pustular 5 3.1

Erythrodermic 6 3.8
Clinical type guttate psoriasis 2 1.3
Inverse 3 1.9
≤720 $ 59 1.3
Income annual 720 $ -7200 $ 97 60.6
in $ ≥ 7200 $ 1 0.6
No formal income 3 1.9
≤ 1 years 15 9.4
2-5 years 45 28.1
duration of 6-10 years 40 25.0
illness in yrs.
11-15 years 42 26.3
>15 years 18 11.3
never married 34 21.3
Married 108 67.5
marriage
The magnitude of metabolic syndrome in psoriasis patient is 23.8%. The most
common comorbidity related to psoriasis is abdominal obesity whichaccountsfor
38.8%(62patients) and the most common clinical type of psoriasis
is plaque psoriasis having 90% (144 patients) followed by erythrodermic psoriasis
condition counts 3.8% (6 patients). higher number of psoriasis patients has <5%
BSA involvement.
45.00%

40.00% 38.8%

35.00% 33.10%

30.00% 28.7%
26.3%
25.00% 23.8% 23.1%

20.00%

15.00%

10.00%

5.00%

0.00%
e n S L A ity
om ns
io
dF
B HD TG s
dr gh be
n rte is e lo
w
Hi lo
sy pe ra in
a
ic y
ol h
do
m
tab Ab
e
m

Figure 1: Proportion of patients with psoriasis get hypertension, increased

FBS, Abdominal obesity, low HDL, and High TGA in alert center, Addis
Ababa, Ethiopia
Among 38 study participants with metabolic syndrome, which moreover appears
slight female patients predominant over male patients, 55.3 % (21 patients) and
44.7% (17 patients) respectively. 28.9% of study participant lay in age group 40-
49 and above 60 each .Out of all metabolic syndrome patients, the majority 73.7%
(28 patients) are married,10.5 % (4) are single and 10.5 % (4) are divorced. Among
38 psoriasis patients who has metabolic syndrome, 57.9% majority (22 psoriasis
patients) earn an income between 720 -7200 $ annually, and 89.5% (34) never
drank alcohol regularly.

Table 2: - Socio-demographic characteristics of patients with metabolic

syndrome patients in alert center, Addis Ababa, Ethiopia.
 metabolic syndrome

( 38 individual )
Frequency with Percentage per
Variable ` group
in each group MetS
18-29 3 7.9
30-39 7 18.9
Age 40-49 11 28.9
50-59 6 15.8
60+ 11 28.9
Male 17 44.71
Sex
Female 21 55.3
Urban 36 94.7
residency
Rural 2 5.3
primary school 16 42.1
secondary school 6 15.8
Vocational (TVET) Level III
Education 2 5.3
status Diploma
Tertiary 6 15.8
No formal education 0 21.1
government worker 6 15.8
Farmer 1 2.6
working status private worker 1 39.5
on pension 4 10.5
other 12 31.6
Plague 36 94.7

Psoriasis Pustular 1 2.6

Erythrodermic 0 0
Clinical type guttate psoriasis 0 0
Inverse 1 2.6
≤720 $ 16 42.1
Income annual 720 $ -7200 $ 22 57.9
in $ ≥ 7200 $ 0 0
No formal income 0 0
≤ 1 years 2 5.3
2-5 years 8 21.1
duration of 6-10 years 9 23.7
illness in yrs.
11-15 years 13 34.2
Clinical profile
Among study individual with metabolic syndrome 52.6% of the study individual
has total BSA involvement greater than ten percent.

34.20%

52.60%

13.20%

≤ 5% 5-10% ≥10%

Figure 2: Total BSA involved in patient with metabolic syndrome in alert

center, Addis Ababa, Ethiopia
Among study individual with metabolic syndrome the most common clinical type
of psoriasis was plague type (95%).

Chart Title
plague pustular inverse

3% 3%

95%

Figure 3: Proportion of patients with metabolic syndrome in each clinical type

of psoriasis in alert center, Addis Ababa, Ethiopia
34%(13) of psoriasis patient with metabolic syndrome has duration of skin lesion
b/n 11-15 yrs. followed by 6-10yrs 23.7%(9).

40.00%

35.00% 34.20%

30.00%

25.00% 23.70%
21.10%
20.00%
15.80%
15.00%

10.00%
5.30%
5.00%

0.00%
≤ 1 yr 2-5 yrs 6-10 yrs 11-15yrs >15 yrs

Figure 4: duration of illness in psoriasis patient with metabolic syndrome in

alert center, Addis Ababa, Ethiopia
Hyper triglyceridemic is the common metabolic syndrome defining comorbidity in
psoriasis patients with metabolic syndrome accounting 32(84.2) followed by
abdominal obesity 27(71.1%).

90.00%
84.20%

80.00%
71.10%
70.00% 68.40%
63.20%
60.00% 57.90%

50.00%

40.00%

30.00%

20.00%

10.00%

0.00%
Hypertension Increased FBS Abdominal obesity Low HDL High TGA

Figure 5 : Proportion of patients with metabolic syndrome get hypertension,

increased FBS, Abdominal obesity, low HDL, and High TGA in psoriasis
patients in alert center, Addis Ababa, Ethiopia

Among study participants with metabolic syndrome 97.4 % (37) are non-smoker
while 2.6% (1) is smoker who smoke less than 20 pack per yr. and 89.5% (34) has
never drink alcohol regularly while 10.5(4) are alcoholic. off those who drink
alcohol 3(75%) drink less than 4 for male and less than 3 for female per day and
1(25%) drink greater than 4 for male and greater than 3 for female per day.
Table3: - Association and binary logistic regression between
sociodemographic characteristics, clinical profile, behavioral factors and
metabolic syndrome
No.Of No.Of

Cumulative odd

Adjusted odd
Percentage
Psorias patients
P
is with P

value
ratio
Variable ` Group
patient MetS value valu
s per per
group group
18-29 33 3 9.1 Reference
30-39 40 7 17.5 0.082 0.01 0.26 0.00
Age 40-49 55 11 20 0.174 0.04 0.020 0.00
50-59 12 6 50 0.205 0.005 0.32 0.00
60+ 20 11 55 0.818 0.784 0.690 0.78
Male 82 17 20.7 Reference
Sex
Female 78 21 26.9 0.71 0.359 0.705 0.60
Urban 128 36 28.1 Reference
Residency
Rural 32 2 6.3 5.87 0.019 18.34 0.05
primary school 52 16 30.8 Reference
secondary
49 6 12.2 0.833 0.731 0.922 0.93
school
Vocational
Education (TVET) Level 17 2 11.8 2.62 0.030 0.279 0.93
status
III Diploma
Tertiary 19 6 1.6 0.250 0.111 0.350 0.45
No formal
23 0 34.8 0.865 0.827 2.990 0.43
education
working Government 33 6 18.2 Reference
status Farmer 16 1 6.3 0.648 0.440 4.067 0.19
private 55 1 27.3 0.194 0.131 1.729 0.78
 on pension 9 4 44.4 1.094 0.843 3.989 0.11
Others 47 12 25.5 2.333 0.253 0.141 0.15
Plague 144 36 25.0 Reference
Psoriasis
Pustular 5 1 20.0 0.667 0.744 0.370 0.54
Erythrodermic 6 0 0 0.500 0.676 0.168 0.52
Clinical
guttate psoriasis 2 0 0 0 0.999 0.000 0.99
type
Inverse 3 1 33.3 0 0.999 0.000 0.99
≤720 $ 59 16 27.1 Reference
Income 720 $ -7200 $ 97 22 22.7 60111 0.999 10040903 0.99
annual in ≥ 7200 $ 1 0 0 473876 0.999 11903174 0.99
$ No formal
3 0 0 1 1 0.002 1.00
income
≤ 1 years 15 2 13.3 Reference
2-5 years 45 8 17.8 0.308 0.195 0.188 0.20
duration
of illness 6-10 years 40 9 22.5 0.432 0.186 0.697 0.70
in yrs. 11-15 years 42 13 31.0 0.581 0.38 0.853 0.86
>15 years 18 6 33.3 0.897 0.856 2.417 0.33
never married 34 4 11.8 Reference
Married 108 28 25.9 0.133 0.075 0.029 0.03
marriage
status Divorced 14 4 28.6 0.350 0.305 0.059 0.03

Widowed 4 2 50.0 0.400 0.430 0.11 0.18

Never 128 Reference

Alcohol
drinking Currently
32 2.532 0.104 9.472 0.03
status /former

Percent of ≤5 63 13 20.6 Reference

BSA 5-10 41 5 12.2 0.468 0.069 0.379 0.13
involveme
nt ≥10 56 20 35.7 0.250 0.012 0.135 0.02
Never 152 3 37 24.3 Reference
Smoking
status Current /former 8 1 12,5% 2.252 0.455 0.827 0.92
Study population who are in age group 30-39(AOR=0.26AND P-value=0.004) ,40-
49 (AOR=0.02 & P-Value =0.001)50-59(AOR=0.205 &P value =0.002), BSA
involvement >10 % (AOR=0.135, P-value =0.023), marriage status of married
(AOR=0.029 P-value =0.036), divorced (AOR=0.059, P-value =0.039), those who
are alcoholic (AOR=9.472, P-value 0.034) had high risk of development of
metabolic syndrome .so age group ,marriage status ,% of BSA
involvement ,alcohol drinking were significantly associated with development of
metabolic syndrome in psoriasis individual,
6 Discussion

Understanding the prevalence of metabolic syndrome in psoriasis patient helps in

better management of psoriasis patients

In this study, hospital magnitude of Mets was 23.8% which is closer to study done
by Parodi, A et, al. (2014). in Italy which is found to be 26.84%.{7}and Case
control study in 2010 by Nisa N, Qazi MA.in India on prevalence of metabolic
syndrome in patients with psoriasis was under taken. the study found that the
prevalence of mets in psoriasis patient was significant 42(28%).{40}.Less
prevalence have been found in other studies like study done by Xin-Yu Gui, Xiao-
Ling Yu,et al 2018in china A total of 859 psoriasis patients ,Metabolic syndrome
occurred in 14.3% of the psoriasis patients.{48} and study done by Adışen,et,al.
(2018) in turkey Metabolic syndrome was found in 12.6% of the patients{1} .our
finding was lower than other studies done by Nasirin G.et,alin 2018 at
Johannesburg The prevalence of metabolic syndrome (MetS) found to be 52.4%
{23}and study done by A Mebazaa, M El Asmi, W Zidi , 2011 Tunisia The
prevalence of metabolic syndrome (MetS)inpsoriasis patients was 35.5% .
{23,36}and also study done by Salam Itani et,al. 2020 in Lebanon prevalence of
mets was 35.3% , in America in 2011 the magnitude of MetS was 40% higher than
our findings.In Sarbia, the study done by Nikico et.al in 2016 MetS prevalence
were 45.1%.The magnitude of MetS in psoriasis patient in the world is variable;
this might be due to variability in genetic make-up, environmental factor and
lifestyle variability{26,32}.

Our study found that high prevalence of MetS in female individuals. This
corresponds to most of other studies.study done by Mebazaa, M El Asmi, W
Zidi , Tunise in 2011, the prevalence of MetS was significantly increased in
psoriatic women .{36}The study done by Adışen,E.et,al turky,2018 the
 prevalence of metabolic syndrome was higher in women than in men. And also
The study in south Africa, Cape town, Overall, metabolic syndrome
components were higher in women compared with men. (1,42}

Our study found the most frequent age group with metabolic syndrome was in
the more than 5th of life this finding corresponds to study done in turkey by
Zindancı, I., et,al 2012 which found that patient aged b/n 40-49 and age over
60+ had an increased risk of metabolic syndrome.{25} Study in cape town by

Peer N, Lombard C,2015 found that high prevalence of mets in age group

55–64 years.{42}

Our study found the magnitude of component of metabolic syndrome in psoriasis

patient was hypertension(23.1%),raised FBS(28.7%),low HDL(26.3%),high
TGA(33.1%)and abdominal obesity (38.8%).this finding correspond to study
done by Milčić D, Janković S, Vesić S serbia 2017, found that All the components
of MetS, except low level of HDL-C,were significantly higher abdominal obesity
(46.7%) raised triglyceride levels (38.1% )high blood pressure (67.2% )and raised
glucose or type 2 DM (31.6% ).{39}

The most common feature of metabolic syndrome in our study was

hypertriglyceridemia followed by abdominal obesity. this finding is not
corresponded to study done by Parodi, A., Aste, N.2014 in America which found
that The most common feature of the metabolic syndrome among patients with
psoriasis was abdominal obesity, followed by hypertriglyceridemia and low levels

of high-density lipoprotein cholesterol.{32}

In our study there is the influence of age group in occurrence of metabolic

syndrome in psoriasis. This finding correspond to study done by Zindancı, I., et,al
2012 in Turky which found that patient aged b/n 40-49 had increased risk of
Mets and5 fold increase of metabolic syndrome in patient age over 60+ .
{25} .This finding is similar with the study in Singapore by Chan, et al. (2020) .
{11}.and we also found that There was There was correlation between severity of
psoriasis and prevalence of metabolic but not with smoking .{11}this finding
correspond to study done in turkey .
7 Limitations of the study
 As a cross-sectional study, the directionality of the association between
psoriasis and MetS could not be determined.
 Absence of previously done study on the topic in this region was also
another challenge.
 Because of Shortage of time& budget it was difficult to perform
extensive study

8 Conclusion
 . prevalence of metabolic syndrome in psoriasis patient is 23.8% .
 Patients with psoriasis should be screened yearly for MetS and risk factors
should be actively controlled
 Psoriasis patients should be informed about the potential metabolic risks and
receive therapies for behavioral changes besides anti-psoriatic treatment in
order to decrease these risks
9 Recommendation
 There should be Regular follow up /checkup for the component
of metabolic syndrome in psoriasis patient
 large scale studies regarding metabolic syndrome in psoriasis
patients should be encourage
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