Is Psoriasis Underdiagnosed and Undertreated in Portugal?

🔍 Key Finding This population-based study suggests that the prevalence of psoriasis in Portugal is 4.4%, and a substantial proportion of individuals with psoriasis are underdiagnosed and undertreated, highlighting the need for improved screening and management strategies. Furthermore, the study revealed a high prevalence of comorbidities, particularly depression/anxiety and cardiometabolic diseases, emphasizing the importance of a multidisciplinary approach to psoriasis care.

🔬 Methodology Overview

• Design: Observational, cross-sectional, nationwide, population-based survey.
• Sample: Random, representative sample of Portuguese individuals with psoriasis and/or psoriatic arthritis.
• Data Collection: Structured phone questionnaire (20 minutes duration) administered by experienced interviewers.
• Inclusion Criteria: Portuguese residents.
• Exclusion Criteria: Individuals in institutional care, communication barriers, businesses/institutions.
• Diagnostic Criteria for Psoriasis: Self-reported physician diagnosis OR self-reported skin disorder with scaling, reddish lesions in elbows/knees/scalp.
• Diagnostic Criteria for Psoriatic Arthritis: Self-reported physician diagnosis OR attending rheumatology for joint problems OR self-reported swollen, painful joint in hands/feet/wrists/ankles/knees.
• Statistical Analysis: Descriptive statistics, Pearson’s chi-squared/Fisher’s exact test, prevalence rate with 95% CI.

📊 Results

• Prevalence: Psoriasis affects 4.4% (95% CI 3.95-4.98) of the Portuguese population, suggesting approximately 440,000 individuals may have the disease.
• Underdiagnosis: 24% of participants meeting psoriasis criteria had suggestive signs/symptoms but no formal clinical diagnosis. A three-year gap was observed between symptom onset and diagnosis.
• Undertreatment: Despite 70% having active disease (scaling, erythema, or pruritus) and 31% experiencing joint symptoms, only 12% were on systemic treatment and 32% were under medical monitoring.
• Comorbidities: 50% of participants with psoriasis reported relevant comorbidities, most frequently depression/anxiety (18%) and cardiometabolic diseases (hypertension 10%, dyslipidemia 10%, diabetes 6%, cardiovascular disease 3%).
• Disease Burden: 16% reported psoriasis interfered with daily activities, 12% with sexual life, and 7% with family life. The median impact on daily life was 5 on a 0-10 scale.
• Psoriatic Arthritis: 42% of psoriasis participants met criteria for psoriatic arthritis, though only 8% had a confirmed diagnosis by a physician.
• Treatment Preferences: Patients prioritized complete lesion resolution (64%), rapid onset of action (65%), and pruritus relief (50%) over quality of life improvement (45%) and treatment safety (41%).

💡 Clinical Impact This study reveals underdiagnosis and undertreatment of psoriasis in Portugal, along with a high prevalence of modifiable risk factors like obesity and sedentary lifestyle. This emphasizes the need for increased public awareness, screening programs, and multidisciplinary approaches incorporating lifestyle interventions to improve psoriasis care.

🤔 Limitations

• Inherent biases from the study design being based on responder data to a questionnaire, including inaccurate recall and interpretation of questions, as well as nonresponse.
• Results should not be extrapolated to other cultural environments with different medical facilities and systems.
• The survey lacked a control group.
• The study did not include a traditional measure of quality of life, such as the Dermatology Life Quality Index (DLQI).
• Definitions were partially based on positive answers to a clinical scenario and not on objective evaluation, potentially leading to over/under-diagnosis of psoriasis and psoriatic arthritis and limiting assessment of disease severity.
• Axial complaints were not considered for the diagnosis of psoriatic arthritis.
• The target sample size was not reached.

✨ What It Means For You This study reveals potential underdiagnosis and undertreatment of psoriasis in Portugal, highlighting the need for increased awareness and screening, especially for psoriatic arthritis. Doctors should consider the patient’s values regarding treatment speed, lesion clearance, and pruritus relief, and prioritize systemic therapies, including biologics, for moderate-to-severe cases and difficult-to-treat areas, while addressing modifiable risk factors like obesity and sedentary lifestyle.

Reference Torres T, Filipe P, Brandão FM, Figueiredo A, Soares AP, Bastos AS, Rebelo C, Correia O, Ferreira P, Brasileiro A, Mendes-Bastos P, Paiva-Lopes MJ, Pinto GM, Severo M, Mendonça D, Oliveira P, Selores M, Massa A, Pereira M, Bello RT; on behalf of the Portuguese Psoriasis Group of the Portuguese Society of Dermatology and Venereology. Epidemiology of Psoriasis in Portugal: A Population-Based Study. Acta Medica Portuguesa. 2023;36:541-549. https://doi.org/10.20344/amp.19048