Do men have more severe psoriasis than women?

Gender perspective in psoriasis: a scoping review and proposal of strategies for improved clinical practice by European dermatologists

Background

The prevalence of psoriasis is similar between men and women; however, evidence exists of sex- and gender-related differences in disease expression, impact, coping, and needs of patients with psoriasis. These differences are essential and should be considered in clinical practice and research.

Objective

To compile available evidence on sex- and gender-related differences in psoriasis, identify the most critical gaps in clinical practice and research, and use it to propose strategies for improved clinical practice.

Methods

Six European dermatologists selected the topics to consider according to their relevance in the dermatology setting with the support of methodologists. Evidence on sex- and gender-related differences was obtained by a scoping review based on search strategies in Medline and Cochrane Library from inception to October 2021 using the following terms: arthritis, psoriatic, psoriasis, gender, and sex. The panel discussed the results and proposed strategies by consensus.

Results

The scoping review identified broad themes: (1) clinical expression, (2) severity and patient-reported outcomes, (3) psychosocial impact, (4) access to treatments and propensity to treat, (5) comorbidities, and (6) treatment effect. The strategies are based on these broad themes.

Limitations

No risk of bias assessment was done due to the scoping nature of the review.

Conclusion

This review offers insights into gender differences in psoriasis, providing a foundation for improving clinical practice and patient outcomes.

The Role of Sex and Gender in Dermatology - From Pathogenesis to Clinical Implications

BACKGROUND

Sex and gender have increasingly been recognized as significant risk factors for many diseases, including dermatological conditions. Historically, sex and gender have often been grouped together as a single risk factor in the scientific literature. However, both may have a distinct impact on disease incidence, prevalence, clinical presentation, severity, therapeutic response, and associated psychological distress.

OBJECTIVES AND PROJECT DESCRIPTION

The mechanisms that underlie differences in skin diseases between males, females, men, and women remain largely unknown. The specific objectives of this review paper are:To highlight the biological differences between males and females (sex), as well as the sociocultural differences between men and women (gender) and how they impact the integumentary system.To perform a literature review to identify important sex- and gender-related epidemiological and clinical differences for various skin conditions belonging to a range of disease categories and to discuss possible biological and sociocultural factors that could explain the observed differences.To discuss dermatological skin conditions and gender-affirming treatments within the transgender community, a population of individuals who have a gender identity which is different than the gender identity they were assigned at birth.

FUTURE IMPACT

With the rising number of individuals that identify as non-binary or transgender within our increasingly diverse communities, it is imperative to recognize gender identity, gender, and sex as distinct entities. By doing so, clinicians will be able to better risk-stratify their patients and select treatments that are most aligned with their values. To our knowledge, very few studies have separated sex and gender as two distinct risk factors within the dermatology literature. Our article also has the potential to help guide future prevention strategies that are patient-tailored rather than using a universal approach.

The impact of gender and sex in psoriasis: What to be aware of when treating women with psoriasis

Psoriasis is a common chronic inflammatory skin disease with an exceptionally high burden for women.

Sex Differences in the Patterns of Systemic Agent use Among Patients With Psoriasis: A Retrospective Cohort Study in Quebec, Canada

Background: Sex differences exist in psoriasis manifestation and expectations from treatment with systemic agents, including, conventional systemic agents (CSA) and tumor necrosis factor inhibitors or ustekinumab (TNFi/UST). However, sex differences in patterns of systemic agent use, such as CSA discontinuation and switch from CSA to TNFi/UST have not been examined.

Objectives: To assess sex differences in patterns of CSA use and identify factors associated with switch to (or add) a TNFi/UST and those associated with CSA discontinuation.

Methods: We conducted a retrospective cohort study using the Quebec health administrative databases. We included patients with psoriasis initiating a CSA in 2002–2015. We excluded patients with a psoriasis diagnosis in the 3 years prior to the first diagnosis date between 2002 and 2015, and those with a systemic agent dispensation in the year prior to that date. We used Cox regression models with the Least Absolute Shrinkage and Selection Operator method to identify factors associated with Switch/add TNFi/UST, and those associated with CSA discontinuation. Separate analyses were performed for male and female patients.

Results: We included 1,644 patients (55.7% females, mean age 60.3 years), among whom 60.4% discontinued their CSA and 7.4%, switched/added TNFi/UST (3.4% switched and 4.0% added) within a median of 0.78 years of follow-up. Among male and female patients, rates of Switch/add TNFi/UST per 1,000 person-year were 49.1 and 41.0 and rates of CSA discontinuation were 381.2 and 352.8. Clinical obesity in male patients (HR 3.53, 95% CI 1.20–10.35), and adjustment/somatoform/dissociative disorders (HR 3.17, 95% CI 1.28–7.85) and use of nonsteroidal anti-inflammatory drugs (HR 2.70, 95% CI 1.56–4.70) in female patients were associated with Switch/add TNFi/UST. Male patients followed by a rheumatologist (HR 0.66, 95% CI 0.46–0.94) and those with a prior hospitalization (HR 0.70, 95% CI 0.57–0.87) were at lower risk of CSA discontinuation, while those initiated on acitretin (vs methotrexate) were at higher risk to discontinue their CSA (HR 1.61, 95% CI 1.30–2.01). Female patients with rheumatoid arthritis comorbidity (HR 0.69, 95% CI 0.51–0.93), those with a dispensed lipid-lowering agent (HR 0.72, 95% CI 0.59–0.88) and hypoglycemic agent (HR 0.75, 95% CI 0.57–0.98) and those initiated on methotrexate (vs all other CSAs) were less likely to discontinue their CSA. Male and female patients entering the cohort between 2011 and 2015 were at reduced risk of CSA discontinuation compared to those entering the cohort before 2011.

Conclusion: Most male and female patients discontinued their CSA within 1 year of follow-up. Our study highlighted sex differences in patients’ characteristics associated with switch/add a TNFi/UST and CSA discontinuation; treatment switch and discontinuation may be indications of treatment failure in most patients.

Differential characteristics and treatment of psoriasis patients by economic status in South Korea: An analysis of the National Health Insurance Database

Despite the enormous burden on patients with severe psoriasis, their utilization of medical care is not well understood in Korea.To compare the characteristics and treatment patterns of psoriasis patients by economic status as well as to examine the factors influencing systemic treatments of psoriasis.We conducted a descriptive cross-sectional study using National Health Insurance sample cohort data in 2015. Psoriasis patients were classified as either the "topical treatment only" or the "systemic treatment" group based on the types of treatment. Patients' economic status was defined by the deciles of health insurance premium, which was determined based on income and assets. Multivariate logistic regression analysis was performed to examine the factors influencing systemic treatments of psoriasis.We identified 6041 psoriasis patients; 39.5% were in the bottom 5 deciles of health insurance premium and 60.5% were in the top 5 deciles. Only 1.9% of the low economic status group and 4.0% of the high economic status group were treated with expensive biologics, although the difference was not statistically significant.Overall, psoriasis patients with higher economic status had a lower likelihood of receiving systemic treatments but had a higher probability of being treated with expensive biologics.

Moderate to severe psoriasis: a single-center analysis of gender prevalence

BACKGROUND

Psoriasis is a chronic, relapsing disease and most epidemiological studies include selected patients undergoing systemic therapies only. Epidemiological data suggest that psoriasis affects 2-3% of the general population, and that men and women are equally affected. The objective was to identify differences in gender for disease severity, patient characteristics and comorbidities in patients with moderate to severe psoriasis, independent of therapy.

METHODS

A retrospective medical chart review of consecutive patients diagnosed with moderate-severe psoriasis at a single center between 2004 and 2017, with a complete set of medical records, was undertaken. Both univariate and multivariate regression analyses were performed. Statistical significance was defined as P<0.05.

RESULTS

The male-to-female ratio revealed a higher prevalence for male gender (2:1, P<0.05). Whilst no significant differences were found for most factors according to gender, age at first evaluation was significantly higher for women. Logistic regression analysis indicated that autoimmune/autoinflammatory diseases were more frequently observed in women, as well as phenotypes other than plaque psoriasis and hypertension. Inversely, dyslipidemia was more frequently associated with male gender.

CONCLUSIONS

Our results show that moderate-severe psoriasis is more common in men and suggests a differential gender distribution of some specific comorbidities in the setting of this disease.

Self-care for older people with psoriasis

Psoriasis affects 1.5% of the UK population and due to the ageing population it is more common in older people. The incidence of type II psoriasis peaks in patients between 57 and 62 years of age, and has different genetic markers. Chronic plaque psoriasis can be challenging for older people as the majority are treated in primary care and expected to self-manage. Community nurses can support older people with psoriasis and their families in understanding current evidence based psoriasis management, and finding solutions to these challenges.

Severity of Psoriasis Differs Between Men and Women: A Study of the Clinical Outcome Measure Psoriasis Area and Severity Index (PASI) in 5438 Swedish Register Patients

Background

Psoriasis is a common skin disease and moderate to severe psoriasis is associated with a dose-dependent risk for metabolic and cardiovascular morbidity. It has previously been speculated that women have less severe psoriasis, as men are overrepresented in psoriasis registers and consume more care.

Objective

The objective of this study was to investigate, for the first time, the sex differences in the severity of psoriasis using the gold standard of severity measurement, the Psoriasis Area and Severity Index (PASI), and the distinct elements of the PASI score.

Design, Setting and Participants

This was a cross-sectional study based on the national registry for systemic treatment of psoriasis in Sweden (PsoReg), with 5438 patients experiencing moderate to severe psoriasis. Differences in the PASI score and its elements at enrolment were tested by multivariable ordinal logistic regressions.

Main Outcome Measures

The different components of the PASI score were used to analyze the assessment of disease severity. For each body area (head, arms, trunk, and legs), the score of the plaque characteristics and degree of skin involvement were used as outcomes.

Results

Women had statistically significantly lower median PASI scores (5.4) than men (7.3) [p < 0.001], which was consistent across all ages. The difference remained statistically significant in a multivariable linear regression. The itemized PASI analyses from the Mann–Whitney–Wilcoxon tests and the adjusted ordinal logistic regressions confirmed that women had significantly lower scores than men in all areas of the body, except for the head. No differences in the use of medications prior to enrolment could be found that may cause this difference between the sexes.

Conclusions

As the PsoReg contains the detailed disease measurement PASI, which was traditionally used for selected participants in clinical studies only, a nationwide unselected population could be investigated. The fact that women have less severe psoriasis can explain the dominance of males in the systemic treatment of psoriasis. These findings motivate a gender perspective in the management of psoriasis and in the prevention and management of its comorbidities.

Gender medicine and psoriasis

The study of specific differences between women and men is arousing huge interests in various fields of medicine, including dermatology. The available data on gender medicine applied to common skin diseases are unfortunately still scanty. Psoriasis is a chronic immune-mediated skin disease which affects 1%-3% of most populations worldwide and can involve also the joints and entheses. The pathogenesis of the disease is very complex, resulting from the interaction between genetic predisposition and several environmental triggers. The pathogenic role of sex hormones has also been hypothesized. The analysis of gender-specific differences in psoriasis seems to suggest some interesting findings, such as an earlier age of disease onset in females, a higher probability of severe disease in men, or different tendencies in care utilization, adherence to treatment, development of psychological distress, and coping strategies. Moreover, sex-related differences have been recently described in some epidemiological and clinical features among patients with psoriatic arthritis. The objective of this article is to review briefly the available evidence regarding gender differences in various aspects of psoriasis, such as epidemiology, genetics, risk factors, associated conditions, quality of life, clinical and therapeutic aspects.

Factors affecting response to biologic treatment in psoriasis

Psoriasis is a chronic, immune-mediated inflammatory skin disease, affecting approximately 2-4% of the population in western countries. Patients with a more severe form of the disease are typically considered for systemic therapy, including biologics. In spite of the overall superiority of biologic agents, the treatment response may differ substantially among individual patients. As with other medical conditions, a range of factors contribute to response heterogeneity observed in psoriasis. Proper identification of these factors can significantly improve the therapeutic decisions. This review focuses on potential genetic and nongenetic factors that may affect the treatment response and outcomes in patients with psoriasis.

The higher proportion of men with psoriasis treated with biologics may be explained by more severe disease in men

Objectives

Moderate to severe psoriasis, once regarded as merely a skin disease, is today seen as an inflammatory systemic disease. The sex ratio of the prevalence of psoriasis is balanced. In recent years several reports have documented that men receive more systemic or UV treatment than women, and different hypotheses were made. In PsoReg, the national registry for systemic treatment of psoriasis in Sweden, we have, like other European registries, observed a predominance of men (59%), especially of men treated with biologics (63%). Biologics are a relatively new group of very effective but high-priced drugs. The objective of this study was to analyse if women are discriminated by not having the same access to the high-priced biologics.

Design

Population based cohort study using data from a nationwide quality register of psoriasis patients.

Population

2294 patients with moderate to severe psoriasis receiving systemic treatment from a specialist in dermatology.

Main Outcome Measures

Time to initiation of biologic treatment. A multiple Cox proportional hazard’s regression was performed, with time to initiating a biologic treatment as the outcome in order to assess the independent role of the patient’s sex in initiating such therapy. The psoriasis severity was defined as a time-varying variable.

Results

Men had more severe psoriasis than women according to the Psoriasis Area and Severity Index (PASI), regardless of age at enrolment, and throughout the study period. The analysis in the multiple Cox regression show that age, psoriasis severity and psoriasis arthropathy were relevant factors for initiating biologic therapy, whereas sex is not.

Conclusions

Although as many women as men are believed to suffer from psoriasis, men seem to be more severely affected by psoriasis. The asymmetry in allocation of biologic therapy thereby probably reflects the differing disease activity between the sexes, and is not a discrimination against women per se.