Journal of Dermatology 2018; 45: 314–317
doi: 10.1111/1346-8138.14101
ORIGINAL ARTICLE
Epidemiological survey of patients with psoriasis in Matsumoto city, Nagano Prefecture, Japan Eisaku OGAWA,1 Ryuhei OKUYAMA,1 Tomoko SEKI,1 Aya KOBAYASHI,1 2 Naoki OISO, Masahiko MUTO,3 Hidemi NAKAGAWA,4 Akira KAWADA2 1
Department of Dermatology, Shinshu University School of Medicine, Matsumoto, 2Department of Dermatology, Kindai University Faculty of Medicine, Osaka-Sayama, 3Department of Dermatology, Yamaguchi University School of Medicine, Yamaguchi, 4Department of Dermatology, The Jikei University School of Medicine, Tokyo, Japan
ABSTRACT A local epidemiological survey of psoriasis was conducted from 19 February to 30 June 2016 in Matsumoto city, Nagano Prefecture, Japan. Patients were predominantly male (268 cases, 71.5% males vs 107 cases, 28.5% females). We estimated that the prevalence of psoriasis was 0.097% in the Matsumoto area. The clinical types of psoriasis identified were psoriasis vulgaris (90.7%), psoriatic arthritis (5.9%), pustular psoriasis (2.1%), guttate psoriasis (1.0%) and psoriatic erythroderma (0.3%). The topical therapeutic agents included corticosteroids (84.0%), vitamin D3 analogs (61.5%), and a combination of calcipotriol and betamethasone dipropionate (31.0%). Current systemic treatments included cyclosporin (9.0%), etretinate (7.4%) and methotrexate (1.3%). Biologic treatments included adalimumab (4.0%), ustekinumab (2.7%), infliximab (1.3%) and secukinumab (0.8%). Ultraviolet B therapy (11.3%) was the predominant phototherapy in which narrow band ultraviolet B therapy accounted for the majority, followed by psoralen and ultraviolet A therapy (1.0%). According to the recent evolution of psoriasis treatment, the use of biologics has been increasing. This study demonstrates the changes of treatment trends of psoriasis in a non-metropolitan regional area.
Key words:
epidemiology, examination, Japan, psoriasis, therapeutics.
INTRODUCTION Psoriasis is a chronic, immune-mediated, inflammatory skin disease and is characterized by inflammatory cell infiltration, epidermal cell hyperproliferation and dilated microvessels. The disease is frequently associated with other chronic and serious health conditions such as metabolic syndromes and cardiovascular disorders.1 Furthermore, psoriasis causes considerable psychosocial disability, thereby exerting substantial burden on the daily life of patients.2 Both genetic and environmental factors are associated to its pathomechanism.3 The estimated prevalence of psoriasis is 0.51–11.43% in adults and 0–1.37% in children over the world.4 The prevalence in Japan is estimated to be lower than that in Western countries.5 The Japanese Society for Psoriasis Research annually conducts an epidemiological survey regarding psoriasis in registered medical institutions, although accurate comprehension of this medical condition is difficult. In this survey, we investigated psoriasis epidemiologically in Matsumoto city, Nagano Prefecture, Japan, to understand the medical conditions of psoriasis in a non-metropolitan regional area.
METHODS The population of Matsumoto city and the surrounding area is approximately 400 000. Dermatologists practicing in this area were asked to participate in this survey. Fifteen dermatological facilities (five hospitals and 10 dermatology clinics) participated in the surveillance of all patients with psoriasis from 19 February to 30 June 2016. This survey included an interview and examination of patients with psoriasis, and data regarding sex, age at disease onset, clinical type of psoriasis, complicating symptoms, current treatments, family and past medical history, and concomitant diseases. The study (3267) was approved by the ethics committee of Shinshu University School of Medicine.
RESULTS Population A total of 394 cases were examined: 268 males (71.5%) and 107 females (28.5%). The age of the patients ranged 2– 92 years (Fig. 1), with a mean age of 59.2 years (standard deviation [SD] = 16.1, males 58.7 and females 61.2), and the
Correspondence: Eisaku Ogawa, M.D., Ph.D., Department of Dermatology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan. Email:
[email protected] Received 26 April 2017; accepted 18 September 2017.
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Table 1. Types of psoriasis
Figure 1. Age and sex distribution of patients with psoriasis registered in our survey.
age distribution was as follows: less than 10 years, 0.8% (three cases); 10–19 years, 0.0% (zero cases); 20–29 years, 1.8% (seven cases); 30–39 years, 7.9% (30 cases); 40–49 years, 20.9% (80 cases); 50–59 years, 18.8% (75 cases); 60– 69 years, 20.2% (81 cases); 70–79 years, 18.6% (72 cases); 80–89 years, 10.2% (42 cases); and 90 years or more, 0.8% (three cases).
Age at psoriasis onset The age at disease onset ranged 0–86 years (Fig. 2), with a mean age of 43.1 years (SD = 19.1, males 43.1 and females 43.6). The distribution of onset was as follows: less than 10 years, 2.1% (eight cases); 10–19 years, 6.2% (24 cases); 20–29 years, 17.1% (66 cases); 30–39 years, 21.6% (83 cases); 40–49 years, 12.7% (49 cases); 50–59 years, 17.7% (68 cases); 60–69 years, 10.9% (42 cases); 70–79 years, 10.1% (39 cases); 80–89 years, 1.6% (six cases); and 90 years or more, 0% (0 cases). Two peaks were observed in the 30s and 50s in men but not in women.
Types of psoriasis and complicating symptoms The major clinical type identified was the plaque type psoriasis, namely psoriasis vulgaris (352 cases, 90.7%) (Table 1). The incidence of other types of psoriasis is shown in Table 1. The
Type
No. of patients
%
Psoriasis vulgaris Psoriatic arthritis Pustular psoriasis Guttate psoriasis Psoriatic erythroderma
352 23 8 4 1
90.7 5.9 2.1 1 0.3
severity of the disease was mild for more than half of the patients (51.6%), followed by moderate (38.5%) and severe (9.9%). The major complicating symptom was itching (65.2%). Other symptoms included scalp lesion (66.0%), nail deformity (29.2%), vulvar involvement (14.0%), joint symptoms of fingers and toes (10.2%), and other joint symptoms (8.9%).
Current treatments Topical treatments included corticosteroids (84.0%), vitamin D3 analogs (61.5%), and a combination of calcipotriol and betamethasone (31%) (Table 2). Systemic treatments included antihistamines (19.4%), cyclosporin (9.0%), etretinate (7.4%), methotrexate (1.3%), corticosteroids (1.1%) and others (4.5%). In addition, the following biologics were used by 8.8% of the patients: adalimumab (4.0%), ustekinumab (2.7%), infliximab (1.3%) and secukinumab (0.8%). Phototherapy included ultraviolet (UV)-B therapy (11.3%; mostly narrowband UV-B) and psoralen and UV-A (1.0%).
Family history Thirty-eight patients had relatives with psoriasis, with the father being the most commonly reported relative (25.7%), followed by siblings (22.9%), children (20.0%), other family members (20.0%) and mother (11.4%). A family history was found in 32 patients with psoriasis vulgaris, two with pustular psoriasis and two with psoriatic arthritis.
Concomitant disorders Hypertension was the highest concomitant disease (37.0%), followed by hyperlipidemia (23.1%), diabetes mellitus (15.0%), gout (including hyperuricemia) (11.4%), ischemic heart disease (5.6%), cerebrovascular disorders (4.2%), tonsil infection (3.3%), other infections (1.9%) and other vaso-occlusive diseases (1.4%) (Table 3). Table 2. Present systemic treatment
Figure 2. Onset of disease in patients with psoriasis registered in our survey.
© 2017 Japanese Dermatological Association
Systemic treatment
No. of patients
%
Cyclosporin Etretinate Methotrexate Antihistamines Infliximab Adalimumab Ustekinumab Secukinumab Corticosteroids Others
34 28 5 73 5 10 15 3 4 17
9.0 7.4 1.3 19.4 1.3 2.7 4.0 0.8 1.1 4.5
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Table 3. Concomitant disorders Concomitant disorders Hypertension Hyperlipidemia Diabetes mellitus Gout, hyperuricemia Ischemic heart disease Cerebrovascular disorder Tonsil infection Infectious diseases excluding tonsil infection Other vaso-occlusive disease
No. patients
of %
133 83 54 41 20 15 12 7
37.0 23.1 15.0 11.4 5.6 4.2 3.3 1.9
5
1.4
DISCUSSION In this study, we conducted an epidemiological survey of psoriasis in Matsumoto city and the surrounding area. Data of 394 patients were collected. The estimated prevalence of psoriasis was 0.097%. Many patients developed psoriasis before or after middle age, and were affected by hypertension and other metabolic diseases. Topical treatment was administrated for the majority of patients. The estimated prevalence of psoriasis was almost 0.1% in our study, which is similar to the previous report in Japan.6 It was lower than those in Western countries and China.4 The prevalence of psoriasis varied worldwide. The results showed that most patients were in their 40s and 70s and developed psoriasis mainly between their 20s and 50s. There were two peaks of psoriasis onset identified (30–39 and 50–59 years) in males. Two distinct subtypes of chronic plaque psoriasis were proposed: early onset psoriasis (presenting in patients aged ≤40 years) and late onset psoriasis (presenting in those aged >40 years).7 The early onset psoriasis was reported to be associated with type 2 diabetes and autoimmune thyroiditis.8 However, in our survey, there was no difference in the ratio of diabetes between early onset psoriasis and late onset psoriasis, and it is unapparent whether the two psoriasis subtypes are different in concomitant disorders. The incidence of psoriasis in males was more than twice as high as that in females. Psoriasis reportedly occurs predominantly in males in Japan,6,9 unlike Western countries where the male : female ratio is equal.9,10 The male predominance was also reported in North India, Taiwan and China.11–13 Therefore, the male predominance may be attributable to a racial factor. In addition, this study showed 9.6% of a family history, which is higher than that of previous reports in Japanese populations: two works reported that a family history was 4.4% and 5.8%.6,9 On the other hand, it was more than 10% in Europe and the USA. Further survey will uncover the correct ratio of family history in psoriasis. Psoriatic arthritis was considered to be relatively rare in Asian countries compared with Western countries (6–42% among psoriatic cases).14 On the other hand, two Japanese groups recently reported that psoriatic arthritis was not uncommon (10.5%, n = 2 581 and 14.3%, n = 3 021).15,16 The incidence in this
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study (5.9%) was lower than them. We covered as wide a range of disease severity as possible in this study, and two-thirds of patients were treated in the clinic and the rest in hospitals. The former two works chiefly targeted patients with psoriasis treated in foundation hospitals, and may include much more severe cases than ours. The important point is that psoriatic arthritis seems to be common even in Japan. In addition, joint symptoms were popular in patients with psoriasis in this study (total = 19.1%), and they should be associated not only with psoriatic arthritis, but also with osteoarthrosis, gout and other diseases. Screening tools may be useful for daily care, such as the “psoriatic arthritis screening and evaluation tool” and “psoriasis epidemiology screening tool”.17 Psoriasis frequently coexists with metabolic syndrome.18–20 This study also showed high ratios of hypertension, hyperlipidemia and diabetes mellitus in the patients with psoriasis, compared with those in Japanese health surveys. Psoriasis is associated with chronic systemic inflammation, leading to the development of metabolic syndrome, including insulin resistance. The insulin resistance is occasionally improved in patients with rheumatoid arthritis treated by tumor necrosis factor-a antagonists and methotrexate.21 Skin improvement may have a favorable influence on metabolic syndrome in patients with psoriasis. New treatment options have recently become available. Understanding the treatment trends is useful for comparing recommendations based on previous research results and guidelines with clinical dermatological practise coupled with the education of patients.
ACKNOWLEDGMENTS: We appreciate the kind cooperation of the dermatologists in Matsumoto city, Azumino city and Shiojiri city. This work was supported by JSPS KAKENHI (grant no. JP 25461688). CONFLICT OF INTEREST:
None declared.
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