This cross-sectional study was conducted among 50 psoriasis patients attending Dermatology, Venereology and Leprosy department (DVL) (out-patient and in-patient) of a tertiary care teaching hospital in Puducherry over a period of six months (October 2017 to March 2018). Convenient random sampling method was adopted. All psoriasis patients with age group more than 18 years, both male and female irrespective of the disease severity were included in this study. Patients who were not able to comprehend the questionnaire and patients with severe medical diseases which may affect their life quality like chronic obstructive pulmonary disease, liver cirrhosis, heart failure, malignant disease and end stage renal disease were excluded. The study was commenced after obtaining approval from Scientific Research Committee and Institutional Ethics Committee (SVMCH/IEC/2017/49). The study procedure was fully explained to the patients after obtaining the written and informed consent.

A specially designed case record form was used to record the patient details like demographic data (name, age, gender, residential address, occupation) usage of medication, questionnaire for assessment of quality of life and treatment satisfaction. Psoriasis Disability Index (PDI) questionnaire was used to assess the quality of life which consists of 10 questions regarding daily activities, employment, personal relationships, leisure, and treatment effects [12]. The answers for each question were given individual marks (very much: 0, a lot:1, a little:2, not at all:2). Summation of the scores indicated the quality of life. The resulting score ranged between 0-45. The scores were expressed in percentage. Higher the score, the quality of life was more impaired. Similarly treatment satisfaction was assessed using Psoriasis Treatment Satisfaction Questionnaire (PTSQ) with three separate sections for topical therapy, phototherapy, and systemic therapy [14]. Satisfaction scores like global, safety of the medication, convenience and proper information provided by the doctor were assessed among the above three therapies. Answers were graded using a 5- point Likert scale and the possible answers scores are 0-very dissatisfied: 1-dissatisfied: 2-undecided: 3-satisfied: 4-very satisfied. The total score was calculated by summing of each answer and generating the possible range of values ranging from 5-25 which were expressed in percentage for comparison. Higher the total score, poorer the quality of life. The PDI questionnaire and treatment satisfaction were adopted based on the previous studies [12,14]. Both the questionnaires were translated in vernacular language before administration to the patients; the questionnaires were back translated to English language and thus, the validity and reliability were reaffirmed (Cronbach’s alpha:0.8).

Data were entered and analysed using SPSS Software 20.0 version (SPSS, Inc., Chicago, IL). Descriptive statistics were performed, mean and SD were used for summarising numerical values; whereas frequency and percentage for categorical variables. One-way ANOVA followed by post-hoc Tukey test was used to assess the disability index and treatment satisfaction. The p-value <0.05 was considered as statistically significant.

In our study, 52% of the subjects belonged to age group ranging 31-50 years and most of the psoriasis patients belong to the middle class category according to modified BG Prasad’s classification (42%). Around 72% of the patients had no co-morbidities as shown in [Table/Fig-1].

A 44% received combination of topical and oral therapy as represented in [Table/Fig-2]. This study was conducted on 3 main groups which include topical, phototherapy and oral and no patients were taking phototherapy alone at present. [Table/Fig-2] was projected to show the distribution among different treatment regimens and their combination both past and current treatment.

[Table/Fig-2]:

Distribution of different treatment regimens among the psoriasis patient.

T: Topical; O: Oral; P: Phototherapy

As represented in [Table/Fig-3], PDI score was high in psoriasis patients with duration of disease more than six months to one year and more than one year compared to disease duration less than six months. [Table/Fig-4] represents the comparison of different treatment regimens like topical, phototherapy and systemic therapy with treatment satisfaction levels (global, safety, convenience and information provided). The total scores were high with phototherapy when compared to other two therapies (p=0.002).

[Table/Fig-4] shows high satisfaction scores for phototherapy according to their answers for their Treatment Satisfaction Questionnaire (TSQ).

Our study highlighted the clinical effect of pattern of different treatment, quality of life and the level of satisfaction among the psoriasis patients treated with topical, phototherapy and systemic therapy. Among the study population (N=50), males and females were 28 and 22 respectively. Patients who received the topical therapy were 45, phototherapy were 14 and systemic therapy were 37 reflecting the maximum number of patients in topical and systemic therapy in our study. This could be due to the severity of the disease as well as location of the lesions. Study done by Horn EJ et al., among the moderate to severe psoriasis patients showed that less than 50% of the patients were receiving systemic therapy similar to our observation [15]. Varma SK et al., studied the pattern of drug prescription in psoriasis patients and analysed most of the patients were effectively treated with topical medications and additional systemic and/or phototherapy were required only for severe cases [16]. The quality of life in psoriasis patients was durable after prolonged use of biologic agents as put forth by Chaptini C et al., [4]. Since psoriasis is a recurrent disease, the affected individuals may experience both disability and significant impairment of quality of life. They were usually assessed by PDI and DLQI questionnaire which is the most often used tools due to their reliability and reproducibility. In this present study, the clinical severity of the disease was measured using PDI questionnaire which showed that the maximum scores were seen with disease duration more than one year when compared to less than one year (p<0.001) indicating the impairment of quality of life in those patients. This was similar to study done by Rakhesh SV et al., who also found a compelling evidence that psoriasis affects the quality of life, and highlighted the importance of adopting a multidimensional assessment of psoriasis [12]. We also observed that 42% of the patients had the disease for more than one year. The present study showed that quality of life was impaired as the duration of disease progressed.

PDI assessment demonstrated greater severity of the disease both physically and mentally but no association between the disease duration and quality of life in a study done by Pakran J et al., contrary to our study [17]. Also, Barot PA et al., showed that DLQI questionnaire scores were high with the section for symptoms and feelings with impaired impacts on the quality of life of the patients [18]. Torres RA et al., demonstrated the quality of life of psoriasis patient by correlating the PDI, PASI and DLQI questionnaire and found out that clinical changes are reflected in the quality of life [19]. The response pattern in our patients could be due to the influence of financial and treatment related problems mostly of the middle (42%) and lower socioeconomic (30%) group.

In addition, the combination of topical and oral treatment perceivers were more than those compared with topical treatments in the form of coal tar, liquid paraffin and steroids which is much better tolerated psychologically and beneficial in our patients.

Our study indicated on the whole that the patients treated with phototherapy were more satisfied when compared to topical and systemic therapy (p=0.002). The global satisfaction for topical and systemic therapy was lower than phototherapy whereas the safety among all the three therapies showed no significant difference. So this shows that phototherapy has been shown to be effective and safe in psoriasis patients. Systemic and topical therapies are lagging behind phototherapy in terms of global satisfaction and convenience. Dissatisfaction with the treatment could lead to discontinuation of the therapy for long-term psoriasis management. Our results were supported by Finch T et al., who found that treatment satisfaction levels were high with phototherapy and systemic treatment whereas global satisfaction levels was significantly lower with topical therapy [14]. Study done by Schaarschmidt M et al., demonstrated that treatment satisfaction of moderate to severe psoriasis showed greater satisfaction for biologicals, followed by traditional systemic medications, phototherapy or topical agents which is in contrary with our study [8]. Yet another study done by Belinchon I et al., also supports the above mentioned observation [20].

Another multicenter study showed 42% of the patients were satisfied with their traditional Chinese or herbal medicines [21]. Our study showed PDI related quality of life has high scores indicating high severity of the disease with poor quality of life. Our observation also showed that treatment satisfaction based on the questionnaire suggesting high level of satisfaction with phototherapy than compared to systemic and topical therapy. The above study provides new insights impacting the quality of life and treatment satisfaction among the patients with psoriasis in our area.

Our study limitations include that it was a cross-sectional and single centered study carried out at a tertiary care teaching hospital. However, the present study could provide a basic data for further larger studies with large sample size at different setting level. The patients answers for the satisfaction questionnaire could be based on the recall of previous and current treatment and also the different combinations adopted in the course of treatment.

Our study highlighted the effect of different dermatological therapy in psoriasis patients. The level of satisfaction based on global, convenience of usage and information provided were high with phototherapy. So the clinicians should consider treatment with phototherapy for patients who require the same. The levels of satisfaction with the treatment in terms of safety were equal among all the three regimens and the quality of life was impaired as the duration of disease progressed.