Epidemiological, clinical and therapeutic profile of patients with severe psoriasis in Rabat Morocco

Sir,

Our paper aims to describe the epidemiological, clinical, and therapeutic aspects of patients with severe psoriasis in Rabat Morocco. We carried out a single-center retrospective, transversal study on 100 cases of severe psoriasis collected between January 2011 and December 2020 at the university hospital ibn Sina Rabat. We included patients with: pustular, erythrodermic, arthropathic forms, and generalized psoriasis vulgaris with a skin surface area>10% and a PASI>15.

The discoveries of our research showed that the age of our patients varied between 4 and 89 years, with a median of 43.5 years, sex ratio M/F was 1.5 documenting a male predominance (61% men, 39% women). The 15% of the patients came from rural areas and 54% were living in poverty. The 21% of patients had a family history of psoriasis. Concerning main comorbidities, hypertension in 8 cases, dyslipidaemia 4 cases, diabetes 4 cases, depression 4 cases, atopic diseases 4 cases, obesity 12 cases, antecedents of smoking, alcohol, and cannabis use noted in 32,15 and 8 cases respectively. The mean duration of uncontrolled psoriasis was 97 months. Symptoms associated (Table 1). Triggers were found in 26% especially in the erythrodermic population. Main factors were, oral steroids, NSAIDs, hydroxychloroquine consumption, stress and solar exposure.

Erythroderma was noted in 21% of cases, palmoplantar keratoderma in 15.6%, pustular psoriasis in 8% of cases, generalized psoriasis vulgaris in 64% of cases, and psoriatic arthritis in 7% of cases. Local treatment with keratolytics (salicylic acid, urea, and white petrolatum ointment), topical corticosteroids or vitamin D analogues was prescribed in 59%, 3% and 4% of cases, respectively. Methotrexate was prescribed in 39% of cases, phototherapy in 15% of cases, retinoids in 6% of cases, cyclosporine in 1% of cases, and biological therapy in 5% of cases. The complications were essentially infectious. The evolution was favorable, complete remission in 35%, partial remission in 15%, 20% of cases have relapsed, and no deaths have been reported.

Psoriasis is a chronic inflammatory dermatosis; its prevalence and incidence vary greatly around the world. In the United States, it affects 2% to 4% of the population.¹ In Morocco the prevalence is 1.79/1000 habitants and the incidence ranges from 1% to 2%.² Only certain forms of psoriasis can be life-threatening (pustular psoriasis and erythroderma), concerning demographic data, psoriasis occurs equally in men and women, we have reported a male predominance, suggesting that severe forms occur more in male patients as reported in a Swedish study where women had significantly (p<0.001) lower median PASI values than men (5.4 for women versus 7.3 for men).^2,3 We documented a significant delay in consultation and in the introduction of systemic treatment probably due to fewer physician visits, difficulty to access to a healthcare facility, economic burden, self- treatment. Our analysis research showed the predominance of erythroderma as the main severe form of psoriasis, as reported by Abdelmoati et al.⁴ Psoriasis has a chronic course ,the relapse rate in our series was in line with other Moroccan studies, 13.75% El Jammal et al and 28% Bouzekraoui et al.^5,6 No deaths have been reported in our series, in contrast with two Moroccan studies reporting a mortality rate of 2.5% and 3.5%.^5,6 In our research ,the mortality rate was probably underestimated because some deaths may have occurred in other hospital departments. In fact, Gelfand et al reported that the risk of death for patients with severe psoriasis was almost double that of patients without the condition, at 1.79 times higher.⁷ Several triggering factors have been reported in the literature, psychological factors have been found in 70% to 100% of cases, in our series only 7% of cases reported bereavement, stress or depression.⁸ Treatment is often difficult, expensive and requires regular monitoring. Even though management approaches of psoriasis are still instructed by high income countries, old therapies are widely used in our practice. Methotrexate remains the mainstay treatment for severe psoriasis in Morocco. Its cost-effectiveness is undeniable, making it the gold standard systemic treatment in developing countries.⁹

Along with the progress in understanding psoriasis pathogenesis, highly targeted and effective therapies have since developed with the perspective not only to improve but to clear psoriasis, their real-world risk-benefit can only be answered by long-term registries, ideally linked internationally and to bioresources.

CONCLUSION

In conclusion, early management of patients including screening for multimorbidity, education and behaviour change, alignment of treatment pathways and prior introduction of systemic therapy. Such interventions, could modify the disease or potentially even halt it by preventing the accumulation of tissue-resident memory T cells in the skin.

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