Resumen de Unattended needs in psoriais: an insight in sexual functioning
BACKGROUND Psoriasis is a chronic, inflammatory skin disease with a worldwide estimated prevalence ranged from 0.9-8.5 %. Its impact upon patient quality of life is remarkable, with social and psychological consequences comparable to those of other diseases such as cancer, heart diseases or diabetes mellitus. Current psoriasis guidelines highlight the importance of screening for physical comorbidities in the comprehensive care of psoriasis patients. Dermatologists represent the axis of the medical care of psoriasis patients and are responsible for these tasks.
Biologic drugs are nowadays the most effective treatment for psoriasis. However, because of economic restrictions depending on clinical setting not all the patients have access to these drugs. In psoriasis, the impact on quality of life does not always correlates with the severity of the disease. Personality factors and coping mechanisms determine the grade of impairment. Most of the patients have persistent and long-lasting lesions, which can difficult their daily lives. What can we do to improve quality of life in patients with psoriasis beyond the skin? Is there an important need that is being unattended in medical consultations? If so, is psoriasis the main cause or are there other factors involved? MATERIAL AND METHODS Our investigation was divided in three stages: 1) Identification of unattended needs, using a Web-site based approach. 2) Review of the available literature. 3) Investigation the involved factors and causal relationships.
1) In order to explore potential unnatended needs of psoriasis patients, we developed a Web site called ¿Psoriasis356¿ and we invited our patients to visit it. ¿Psoriasis365¿ is hosted in URL:https://sites.google.com/site/psoriasis365/.
After the study period, we analysed the Web traffic. The ¿practical advice¿ section (Consejos Prácticos) was the most visited section. This ¿practical advice¿ section discusses everyday issues related to living with psoriasis, and includes practical suggestions for common situations such as facing exams, meeting new people and sexual relationships. In particular, the ¿sexual relationships¿ section was the most visited page of the Website. Sexual function seems to be an important topic for psoriasis patients that are not sharing with their dermatologists.
2) As a consequence of the previous analysis, we performed a systematic review in psoriasis and sexual function to explore and analyse the available scientific evidence in the topic. We conducted a literature search of major biomedical databases with the following search terms: "psoriasis" AND ("sexual dysfunction" OR "sexual"). All types of epidemiological studies regarding sexual function in patients with psoriasis were included. Reviews and case-reports were excluded. Two independent reviewers examined the title and abstract of the articles obtained in the first search to recognize relevant studies. Full texts of all studies meeting the inclusion criteria were reviewed, and their bibliographic references were checked for additional sources. The articles upon whose relevance both reviewers agreed were included in the analysis. The variables assessed were: the type of study, sample size, instruments used, statistical analysis; and results.
3) We observed that patients with psoriasis probably have an increased risk of sexual dysfunction. But the causal mechanisms involved are still controversial. Consequently, we performed a study to explore the factors that increase the risk of sexual dysfunction in psoriasis patients compared to healthy population and to build a risk profile of the psoriasis patient candidate to have sexual dysfunction. We conducted a prospective case series study of patients with moderate to severe psoriasis. The study sample was recruited from the patients attending their scheduled follow-up visits to the psoriasis unit of the University Hospital of Granada. Socio-demographic data and biometric parameters were collected through clinical interview and physical examination. The main variables were the presence of sexual dysfunction, problems of anxiety and/or depression, and the distribution pattern of psoriasis. The Massachusetts General Hospital-Sexual Functioning Questionnaire (MGH-SFQ) was used to assess sexual function. The Hospital Anxiety and Depression Scale (HADS) was used to evaluate the anxiety and depression levels. The human diagram of the Self Administered Psoriasis Area and Severity Index (SAPASI) was used to assess the distribution pattern of the psoriasis lesions. Data were coded from the diagram into 22 body areas.
RESULTS 1) The Web site, ¿Psoriasis365¿ showed that sexual function is an unattended need in patients with moderate to severe psoriasis.
2) The results of the systematic review of the scientific literature showed that psoriasis patients have probably and increased risk of sexual dysfunction. But the risk factors in this relationship are still not well defined.
3) The results of our study showed that psoriasis is a risk factor of sexual dysfunction in general but not for erectile dysfunction in particular. Other factors probably associated to the higher prevalence of sexual/erectile dysfunction in patients with psoriasis are anxiety and depression, smoking or arterial hypertension-antihipertensive drugs. We observed that the severity of the disease barely correlates with the presence of sexual dysfunction, but the distribution pattern of psoriasis is important in terms of sexual functioning. We analysed the impact of the location of the psoriasis lesions upon sexual function. We observed that certain distribution patterns of lesions: abdomen, genitalia, lumbar region and buttocks in women and chest, genitalia and buttocks in men ¿renamed as Areas of Sexual Interest- are associated to a higher probability of sexual dysfunction.
and physical comorbidities like arterial hypertension or smoking.
CONCLUSIONS Sexual function is impaired in moderate to severe psoriasis patients as a consequence of changes in body image and the accumulation of other factors independently associated to sexual dysfunction. Patients with psoriasis are concerned about it and require information about psoriasis and sexuality. Dermatologists have the opportunity to discuss this topic with the patients and look for individuals with higher risk. With this purpose the areas of sexual interest identified in the current investigation could be useful, if they are implemented during the routinely physical examination. By improving sexual functioning in patients with psoriasis we can significantly improve their overall quality of life.
