Prevalence, Co-morbidities and Management of Psoriasis in Saudi Arabia: A Review

Background: Psoriasis is a chronic inflammatory skin illness with an autoimmune pathogenic mannerisms and genetic tendency. It is regarded as erythematous plaques sheltered with silvery scales predominantly over the extensor exteriors, scalp, and lumbosacral region. The prevalence in Saudi Arabia was projected to be 5.3% (53% of psoriasis patients develop it before 30 years of age. 
Aim: The main objective of this study is to summarize the current evidence regarding prevalence, types, risk factors, associated comorbidities and management of psoriasis in Saudi Arabia. 
Methods: This is a systematic review was carried out, including PubMed, Google Scholar, and EBSCO that examining previous studies regarding psoriasis in KSA. Authors extracted the data, and then the author's names, year and region of publication, the study type, period of study, and the result were reported.                                                                                     
Results: The review included 7 studies that illustrate prevalence, types, risk factors, associated comorbidities and management of psoriasis in Saudi Arabia.             
Conclusion: The incidence of psoriasis in Saudi Arabia is within previously reported figures worldwide. Family history seems to have a strong association with the occurrence of psoriasis. CVD and psychological disorders seem to be prevalent Saudi psoriatic patients. Topical medications are widely used and effective in psoriasis management in Saudi Arabia.


INTRODUCTION
Psoriasis is defined as a chronic inflammatory skin illness with an autoimmune pathogenic mannerisms and genetic tendency. It is regarded as erythematous plaques sheltered with silvery scales predominantly over the extensor exteriors, scalp, and lumbosacral region [1]. The international prevalence is around 2%, but differs rendering to regions with lower prevalence in Asian and some African residents, and 11% in Caucasian and Scandinavian residents [2]. The prevalence in Saudi Arabia was projected to be 5.3% (53% of psoriasis patients develop it before 30 years of age [3]. Psoriasis normally affects the skin, but sometimes joints can be affected (about 10% of patients develop severe deforming arthritis). It has been reported to be associated with other diseases. Organ systems can also be affected by inflammation as it is not limited to the psoriatic skin [4].
The precise etiology is indefinite, but it is considered to be an autoimmune disease mediated by T lymphocytes. Family history suggests its genetic predisposition. Also, mechanical, chemical, and radiation trauma induces lesions of psoriasis as well as certain drugs such as chloroquine, lithium, betablockers, steroids, and NSAIDs which worsen psoriasis [5]. There are a number of multiplicities of psoriasis, including plaque psoriasis, inverse (flexural) psoriasis, pustular psoriasis, and guttate psoriasis. The dermatological symptoms of psoriasis are varied; psoriasis vulgaris is also called plaque-type psoriasis, and is the most prevalent type [6].
Psoriasis is known to have a negative influence on patient's quality of life as well as their family members. Remissions are experienced in 10-60% of patients. Psoriasis has been associated with depression, suicide, smoking, substance abuse, alcoholism, metabolic syndrome and a variety of skin cancers. Also, patients incline to have major comorbidities as kidney disease, heart disease (as noted in several previous studies), and joint problems [7].
Topical treatment is recommended in mild to moderate cases, while phototherapy includes PUVA therapy combines psoralen with exposure to ultraviolet light (UVA), as well as NBUVB (Narrowband UVB light) is recommended in severe cases. Systemic drugs as methotrexate, retinoids, cyclosporine, and fumarates are possible options that can be used in severe psoriasis cases in which nails are involved and psoriatic arthritis [8].

Aim of the Study
The main objective of this study is to summarize the current evidence regarding prevalence, types, risk factors, associated comorbidities and management of psoriasis in Saudi Arabia.

Searching
PubMed and EBSCO data bases were searched for the publications used in the study, as they are known to be high-quality sources of information. PubMed is one of the leading online databases established by the National Center for Biotechnology Information (NCBI). Articles regarding psoriasis in Saudi Arabia as well as other articles were used in writing the article. Limitations to English language due to insufficient translation services have been applied. Papers were screened by names, and the abstracts reviewed 6 articles that were eligible.

Data Extraction
In the first stage, authors screened the titles and abstracts identified from searching the databases for eligibility. Eligible papers were critically appraised and those meeting the inclusion criteria were selected for data extraction.

Criteria for Inclusion
Papers were chosen on the basis of importance to the topic, including one of the following topics: epidemiology of psoriasis in Saudi Arabia, associated comorbidities among psoriasis patients in KSA, psoriasis in Saudi Arabia'.

Criteria for Exclusion
Papers not important to the topic, including articles outside Saudi Arabia and all other publications that did not consider our scope (epidemiology of psoriasis in Saudi Arabia, associated comorbidities among psoriasis patients in KSA, psoriasis in Saudi Arabia) or repetitive research, and summary studies were omitted.

Statistical Analysis
No technology was used to analyze the results. Information collected was derived on the basis of a particular type (Publication Title, Author's Name, Purpose, Description, Findings and Outcomes). This data were checked by the group members to obtain a uniform results. Double review of the results of each member has been implemented to ensure authenticity and eliminate errors.

RESULTS
A total of 66 research used for the title screening contributed to the search. 35 of them had been used for abstract screening, which contributed to the omission of 12 papers. The remaining 23 fulltext articles have been examined. The full-text revision helped lead to exclusion of 17 studies and 6 were able to enroll for final extracting data ( Table 1).
The included studies had different study designs.  There is a higher CV risk prevalence among Saudi psoriatic patients and this confirms that psoriasis is an independent CV risk factor in this population.
[11] Mleeh, Nouf T et al. [12] reported that psychosocial valuation should be defined when evaluating and treating psoriasis as it may help in reducing exacerbation of symptoms, mainly for conditions aggravated by stress.
Bhutto A, M, et al. [13] reported that; the age of children ranged from 8 months to 18 years (mean=11.27 years). Of all studied cases, (16.7%) had the localized lesions on elbows and knees, (11.1%) had the localized lesions on hands and feet and (2.8%) had on scalp. The duration of the disease ranged from 2 months to 11 years (mean=3.04 years). The male and female prevalence ratio was 1:1.4 respectively. 27.8% of cases reported positive family history.

DISCUSSION
In Saudi Arabia; Fatani, Mohamad I et al. [3] reported incidence around 5.3%. This was higher than reported in Russia 31.4 per 100 000 person years [15] and comparable to Germany 521.1 per 100 000 person years [16]. Springate and colleagues [17] reported a slight decline in the incidence of psoriasis in all ages in the United Kingdom from 159.0 to 129.0 per 100 000 person years between 1999 and 2013). Kubanova and colleagues [18] also reported a slight decline in the incidence in Russia (from 69.8 to 65.0 per 100 000 person years between 2010 and 2016). However, the incidence of psoriasis in Denmark has been inconsistent, with a decrease from 140.1 to 104.0 per 100 000 person years between 2003 and 2005, followed by an increase to 181.0 in 2010 [19].

CONCLUSION
The incidence of psoriasis in Saudi Arabia is within previously reported figures worldwide. Family history seems to have a strong association with the occurrence of psoriasis. CVD and psychological disorders seem to be prevalent Saudi psoriatic patients. Topical medications are widely used and effective in psoriasis management in Saudi Arabia. Future studies are recommended with large sample size to assess updated incidence and document association between psoriasis and other comorbid diseases.

CONSENT
It is not applicable.