**4. Results**

Declaratively, the prevalence of psoriasis in the studied group (N = 1500) reached 4.2%, the first symptoms appearing around the age of 50 and a competent diagnosis being required by the patients around the age of 55. A series of studies carried out all over the world suggests that Caucasians are more affected than other races, with higher prevalence percentages, unlike Australian Aborigines, the pre-Colombian population of the New World, Andean Indians, Amerindians, Alaskan, Canadian, or Native Americans of the United States, where psoriasis has been reported to be extremely rare or absent [12]. Interestingly, late-onset psoriasis is slightly more common than the early-onset type, contrary to the often quoted convention that 75% of new psoriasis cases are present before the age of 40 [13].

Neither the environment, urban/rural, nor the type of locality presents statistical data or is associated with the presence of psoriasis for the 1500 individuals or for the 461 remaining subjects from the subgroup of 500 randomly selected individuals in the second stage of the study (Table 2). In contrast with an Italian study [14], psoriasis did not seem to be homogeneously distributed across the northern, central, and southern geographical areas of the country, findings which are similar to a study in Spain [15]. These variations in prevalence rates between regions are not unusual and are explained by different genetic and/or financial and stress conditions.


**Table 2.** Demographic characteristics depending on the presence of psoriasis vulgaris.


**Table 2.** *Cont.*

The psoriatic patients, but not the healthy group, were usually supervised by the doctor, with a few exceptions (although they were selected by a doctor, perhaps the exceptions indicate a lack of understanding of the question). With rare exceptions, psoriatic patients report that they follow a treatment; no subject who is considered healthy is considered to be under treatment. Patients with psoriasis had significantly more frequent relatives with psoriasis than the healthy group.

Skin lesions appeared significantly more frequently in psoriatic patients than healthy people, but also in 3/4 of healthy people. Lesions of the elbows or knees have been reported very frequently by psoriatic patients and very rarely by healthy people. To a lesser extent, the lesions on the scalp, hands, feet, back, and to a very small extent other skin lesions had a differentiating value. An association with psoriasis in general is also observed for scales, pruritus, red areas, bleeding areas, frequent in psoriasis, but quite common in healthy people. The same association shows the disappearance with local treatment. Persistence of lesions does not appear to be associated with psoriasis, but the occurrence of lesions under stress, including pruritus, was reported more frequently by psoriatic patients. Increasing evidence over the past decade has shown that pruritus can be one of the most prevalent and burdensome symptoms associated with psoriasis, affecting almost every patient to some degree [16]. Spontaneous disappearance is relatively rare, but more common in healthy people. Small nail stains are reported significantly more frequently by psoriatic patients than healthy ones and nail loss is rare in both psoriatic and healthy individuals (Table 3).


**Table 3.** Results and data analysis of the national study (N = 1500 respondents).


**Table 3.** *Cont.*

Comorbidities and strong related conditions are detailed in Table 4. Smoking is significantly more common in psoriatic patients than healthy people and also, the age of the onset of smoking does not make a difference. There is no difference between a former smoker or a passive smoker and the gross variables regarding the intensity of smoking exposure do not show, individually, differences between the studied groups. The link between alcohol consumption seems vague, the only more convincing association being with the concern of loved ones in the last year, which is significantly more common in those with psoriasis. The report of pharyngitis in childhood was insignificantly more frequent in psoriasis, but the reports of hospitalizations for pharyngitis in childhood were significantly more common in psoriasis. There were no significant differences in height, body weight, or maximum body mass in the groups. The diagnosis of depression as well as the treatment were significantly more frequently associated with psoriasis. Patients with mild psoriasis can experience psychiatric comorbidities; however, depression is more common in patients with severe psoriasis or psoriatic arthritis [17].

**Table 4.** Comorbidities and related conditions resulting from the national study (N = 1500 respondents).


Of the 500 subjects selected for clinical examination, 461 attended the visit.

In this study group, the prevalence for psoriasis vulgaris was 4.99% (2.95: 7.03). The concordance between the initial diagnosis, established on the basis of the questionnaire and the final clinical diagnosis was 99.13% for psoriasis vulgaris. An acceptable sensitivity of the questionnaire more than 85% and a specificity of almost 100% were identified.

Regarding the treatment for psoriasis, only 2 of the clinically confirmed cases of the disease reported following treatment, while 7 did not receive treatment and 15 did not answer the question. Only one subject who considered himself healthy declared to be under treatment. Some psoriasis patients, even some dermatologists, are quite reluctant to undertake biologic therapy [18], even though it has demonstrated real efficacy in treatment of psoriasis and psoriatic arthritis [19], but novel biologics act by novel targets, technology, and mechanisms of action compared to previously approved biologics and the explosive development of biological therapy and the emergence of biosimilars, revolutionary tools against the most serious and provocative diseases which represent a significant success in the effort to provide advanced healthcare to patients all over the world [20–22]. To complete these results, an interesting study provides useful data on widely used biologic drugs and their tolerability, discontinuation rate, and the incurrence of severe adverse events [23].

We have detailed the data obtained from the national study regarding healthy and non-healthy groups in Table 5. Regarding the hereditary factors, patients with psoriasis significantly more frequently had relatives with psoriasis compared to those without disease. This result was also confirmed in the initial group. The frequency of reported skin and nail lesions differ significantly between the psoriatic patients and the disease-free, unlike the initial group in which the yellowing of the nails was significantly associated with the certified diagnosis of psoriasis. Regarding smoking, the only significant difference was identified for smoking exposure in the last 12 months, present in 21.1% of psoriatic patients and in none of the healthy patients. Moreover, alcohol consumption in the last year has never been significantly associated with an increased likelihood of the disease. Regarding infections, the data correspond to the results of stage 1. Many systemic therapies available for the management of psoriasis patients who cannot be treated with more conservative options, such as topical agents and/or phototherapy, can worsen or reactivate a chronic infection. Therefore, before administering immunosuppressive therapies it is mandatory to screen patients for some infections, including hepatitis B or C [24,25]. Metabolic syndrome is a highly prevalent, multifaceted condition characterized by a constellation of abnormalities that include abdominal obesity, hypertension, dyslipidemia, and elevated blood glucose [26]. The frequency of obesity was not significantly different between the psoriatic and the non-psoriatic patients (Table 5). Psychological stress has long been shown to play an important role in the natural history of psoriasis, but the details of this relationship remain to be clearly defined [27]. In the initial group, 5% of the interviewees stated that they often felt that they could not cope with the important things in life. In the diagnostic group, the proportion of those who chose the "very often" option on this question was 4.2% in non-patients and 8.7% in those with psoriasis, respectively. The difference did not reach statistical significance (*p* = 0.342).

**Table 5.** Results and data analysis of the national study (N = 1500 respondents).



#### **Table 5.** *Cont.*

#### **5. Discussion**

In our study we elaborated a screening questionnaire for the early presumptive diagnosis of psoriasis and we applied this tool on a randomly selected sample of 1500 subjects from the general population.

In a second stage of the study, a group of 500 subjects (comparable to the initial sample by gender, age, area of residence, region, level of education) was selected to be examined clinically at the same time, for a certain diagnosis. Among the analyzed risk factors, a significantly higher presence of family history in patients was also confirmed, in accordance with the predictive model, while for the rest of the analyzed factors there were no significant differences between psoriatic and non-psoriatic patients.

Our study has some limitations related to the fact that only one third of the initial sample has received a medical examination due to feasibility reasons. We tried to minimize those limits by randomly selecting the subjects and therefore revealing the similarities of the two groups from demographic and geographical perspectives. Another limitation is related to the fact that only 23 patients with psoriasis have been identified in the subgroup of people with a medical examination. We used for comparisons in this case the Fisher test and the demographic and geographical characteristics did not differ significantly for psoriatic and non-psoriatic patients. Last but not least, we did not measure the concordance between different dermatologists who have been involved in the clinical diagnosis.

#### **6. Conclusions**

The pilot study demonstrated the ability of the questionnaire and the procedure for completing it to highlight the most expected associations based on the literature on the epidemiology of psoriasis.

Our study is the first attempt, upon our knowledge, to estimate the prevalence of psoriasis in Romania. The prevalence of psoriasis vulgaris measured within the second stage of the study was 4.99% and the proposed questionnaire was found to have a convenient sensitivity for psoriasis vulgaris (86.96%). The correlation between the declared diagnosis established on the basis of a questionnaire and the final clinical diagnosis was 99.13% for psoriasis vulgaris.

Further research is required to determine the reasons driving the increase in psoriasis prevalence over time. The results obtained in this study are intended to be a source of recommendations and suggestions for new initiatives, campaigns, and public policy proposals to address the various issues of these diseases.

**Author Contributions:** All authors had equal contribution. Conceptualization A.C.N., M.M.C., C.G., S, .B.; data curation L.G.-S., T.C.; formal analysis A.C.N., M.M.C., F.F., I.A.; supervision A.C.N., M.M.C., T.C., C.G.; writing—original draft S, .B., L.G.-S., T.C.; writing—review and editing M.M.C., T.C., S, .B., F.F., I.A. All authors have read and agreed to the published version of the manuscript.

**Funding:** Romanian Society of Dermatology; Eli Lilly; Novartis; Abbvie; Johnson & Johnson.

**Institutional Review Board Statement:** The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Ethics Committee of Scientific Research (no. 26/05.11.2018).

**Informed Consent Statement:** Informed consent was obtained from all subjects involved in the study.

**Acknowledgments:** The authors express their thanks for the support received from the Romanian Society of Dermatology, Totem Communication, Abbvie, Eli Lilly, Novartis, Johnson & Johnson.

**Conflicts of Interest:** No conflict of interest to declare.

**Ethics Committee:** The study has the approval of the Scientific Research Ethics Committee no. 26/05.11.2018.
