JOURNAL CLUB

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
Current Situation of Leprosy in India and its
Future Implications
 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.
 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.
• 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.
• 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
• 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 .
 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.
• 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.
• 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.
• 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
• 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.
 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.
• 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.
• 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
• 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.
 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.
• 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%.
• 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.
• 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
• . 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.
 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.
• 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.
 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.
 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
 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.
• 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%).
• 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.
 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%.
• 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.
• 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
• 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.
Newer Topical Treatments
in Skin and Nail
Dermatophyte Infections
• 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
• 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.
 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
• 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.
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.
• 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).
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.
• 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.
• 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
 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.
• 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.
• 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
 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.
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)
 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.
 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.
 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.
 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
 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.
Correlation between Disease Severity,
Family Income, and Quality of Life
in Psoriasis: A Study from South India
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.
Materials and Methods
• Justice KS Hegde Hospital attached to KS Hegde
Medical Academy, Mangalore

• 102 patients from Oct 2015 to march 2017

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.
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.

 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%)
• 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.
• 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).
• 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.
 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.
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.
• 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.