Management of psoriasis in Africa and the Middle East: A review of current opinion practice and opportunities for improvement

Management of Psoriasis in Africa and the Middle East: a Review of Current Opinion, Practice and Opportunities for

Improvement

M A BDULGHANI ¹ , A A L S HEIK ² , M A LKHAWAJAH ³ , A A MMOURY ⁴ , F B EHRENS ⁵ , H B ENCHIKHI ⁶ , I B ENKAIDALI ⁷ , N D OSS ⁸ , A E L G ENDY ⁹ , I M OKHTAR ¹⁰ , D O DENDAAL ¹¹ , N R ABOOBEE ¹² , D T HAÇI ¹³ , R W EISS ¹⁴ AND D W HITAKER ¹⁵

1

Department of Dermatology, King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia;

2

Department of Dermatology, King Fahad National Guard Hospital, Riyadh, Saudi Arabia;

Department of Dermatology, College of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia;

Division of Dermatology, St

George Hospital University Medical Centre, Beirut, Lebanon;

Department of Rheumatology, and

Department of Dermatology, Venereology and Allergy, JW Goethe

University, Frankfurt/Main, Germany;

Faculty of Medicine, Hassan II University, and Department of Dermatology and Venereology, Ibn Rochd University Hospital, Casablanca, Morocco;

Faculty of Medicine, Centre Hospitalo-Universitaire, University of

Algiers, Mustapha Algiers, Algeria;

Department of Dermatology, Military Hospital of Tunis, University of Tunis El Manar, Tunis, Tunisia;

Dermatology Department, Banha University, Banha, Egypt;

Department of Dermatology, University of Tunis El Manar, Tunis, Tunisia;

Neoderm Cosmetic and Dermatology Centre, Port Elizabeth, South Africa;

Westville Hospital, Westville, Durban, KwaZulu Natal, South Africa;

Rosebank Clinic, Rosebank, Johannesburg, South Africa;

Private Practice, Kenilworth, Cape Town,

South Africa

Psoriasis is a common, chronic, systemic, inflammatory disease of the skin that is often associated with inflammatory musculoskeletal disease. Psoriasis impacts on affected individuals and on society at many levels, being associated with considerable economic burden and impaired quality of life. This article aims to provide dermatologists and their allied healthcare professionals, particularly those practicing in Africa and the Middle

East, with a review of the current understanding of psoriasis, its treatment and impact, as a backdrop for further discussion of the management of psoriasis in these regions. Insight into the real-life, day-to-day challenges and unmet needs currently facing dermatologists in Africa and the Middle East is provided by the authors, most of whom are experienced dermatologists practicing in this region.

KEY WORDS: P SORIASIS ; P SORIATIC ARTHRITIS ; A FRICA ; M IDDLE E AST ; P ATHOPHYSIOLOGY ;

C OMORBIDITIES ; C ARDIOVASCULAR ; M ETABOLIC

Introduction

Psoriasis is a systemic, relapsing, hyperproliferative disease of multifactorial origin,

which remains under-recognized and undertreated worldwide.

Literature regarding psoriasis and its management in the geographically large, culturally diverse and ethnically heterogeneous regions of Africa and the Middle East remains limited compared with the large volume of data from the Western world. Isolated studies have reported on the incidence of psoriasis in Africa and the Middle East, including two small, single-centre studies, conducted in 2004 and 2005 that found the incidence of psoriasis to be 1.5% and 3.4%, in south-western and eastern Saudi Arabia, respectively.

A larger study conducted across five hospitals in Johannesburg, South Africa, found the incidence of psoriasis to be 9.6% in patients of Indian ethnic origin.

Interestingly, psoriasis did not commonly affect any of the other ethnic groups in the study.

The prevalence of psoriasis is estimated at 1 – 3% in Western Caucasian populations.

The present article provides dermatologists, and other healthcare professionals involved in the routine care of psoriasis patients, with a brief review of the current understanding of psoriasis in the context of disease management in Africa and the Middle East. The authors comprise a panel of 14 experienced, practicing dermatologists from Africa (Algeria, Morocco, Tunisia, Egypt and South Africa) and the Middle East (Lebanon and Saudi Arabia) and one rheumatologist from Germany, who discussed at length the current real-world challenges and unmet needs in the management of psoriasis in Africa and the Middle East. Strategies for overcoming barriers to better management were developed and are presented below.

Psoriasis: an overview of pathophysiology

The aetiology of psoriasis remains unknown, but emerging evidence describes a complex disease arising from interactions between multiple genes, the immune system and environmental factors.

Familial studies indicate a genetic basis for psoriasis: up to 71% of patients with childhood psoriasis have a positive family history; concordance rates are three- to four-fold higher in monozygotic twins than dizygotic twins; and there is linkage to the major histocompatibility complex region.

Eight genomic loci have been found to be associated with psoriasis, seven of which harbour genes with recognized immune functions (interleukin-28 receptor- α [IL28RA], v-rel reticuloendotheliosis viral oncogene homologue (avian) [REL], interferon induced with helicase C domain 1 [IFIH1], endoplasmic reticulum aminopeptidase 1 [ERAP1], tumour necrosis factor (TNF) receptor-associated factor 3 interacting protein 2 [TRAF3IP2], nuclear factor- κ light polypeptide gene enhancer in B-cells inhibitor α [NFKBIA] and tyrosine kinase 2 [TYK2]).

There is increasing evidence that

activated T cells are the primary modulators

of the pathogenesis of psoriasis.

The

characterization of cells and cytokines

involved in disease initiation and

maintenance found elevated levels of

interferon (IFN)- γ and interleukin (IL)-12, but

not IL-4, IL-5 or IL-10, which provides the

basis for the definition of psoriasis as a T

helper (Th) type-1 disease.

IL-17-producing

Th (Th17) cells play a role in autoimmunity,

together with IL-23, which is an important

regulator of Th17 cells and a key initiating

cytokine in the development of

autoimmunity.

Elevated levels of both IL-

23- and Th17-related cytokines in the

cutaneous lesions and sera of patients with psoriasis, together with clinical data demonstrating the therapeutic efficacy of T cell-targeted drugs, further support a role for T cells in psoriasis.

Evidence suggests that environmental factors – including smoking, alcohol, diet, elevated body mass index, skin trauma, systemic viral or bacterial infection, systemic medications (for example, lithium and β - blockers), and stressful life events – are associated with psoriasis.

A study involving French and Tunisian patients identified six statistically different clusters of clinical symptoms, corresponding to six different psoriasis phenotypes.

These findings add further weight to the hypothesis that psoriasis may not be a single disease entity but, instead, comprises distinct disease phenotypes that differ in terms of pathophysiology and responsiveness to treatment.

Diagnosis and assessment of disease severity

The diagnosis of psoriasis is not a challenge for the experienced dermatologist and is based on the recognition of well demarcated, erythematous, scaly plaques commonly localized on predilection sites (scalp, elbow, knee and lumbosacral region).

Histological findings include: hyperparakeratosis;

uniform acanthosis with elongated rete ridges and suprapapillary thinning over elongated dermal papillae; collections of neutrophils in tiny unicellular pustules (Kogoj pustules) and larger confluent abscesses (Munro microabscesses) in both spinous and cornified layers; superficial lymphocytic perivascular infiltrate with an admixture of occasional neutrophils; and ectatic capillaries in the elongated dermal papillae. Chronic plaque psoriasis is the most common form, occurring in around

80% of cases, and other clinical variants include pustular psoriasis, erythrodermic psoriasis and guttate psoriasis.

The severity of psoriasis can be assessed using the Psoriasis Area and Severity Index (PASI), Body Surface Area (BSA) and Psoriasis Global Assessment (PGA).

Of these tools, PASI is the most extensively studied and has been thoroughly validated.

Psoriasis has a significant, detrimental, measurable impact on quality of life (QOL).

The reduction in QOL in patients with psoriasis is at least equivalent to that seen with other serious chronic diseases, including ischaemic heart disease and diabetes, with cases of depression and suicidal ideation reported among patients.

The negative impact of psoriasis on QOL has been studied in countries including Kuwait, Iran and Tunisia, with findings similar to those from Western countries.

Psoriasis adversely affected physical activity and social relationships in ≥ 50% and sexual activity in 33% of 330 Kuwaiti outpatients with psoriasis, as measured by the Dermatology QOL scale.

The QOL outcomes can sometimes be underestimated by disease severity scores.

A weak association between PASI score and impaired QOL was reported in one prospective observational study,

and another found that the relationship between disease severity score and QOL was only significant for lesions located on visible body parts.

There are many validated instruments

that can be used to measure the impact of

various aspects of psoriasis on QOL,

including the Dermatology Life Quality

Index (DLQI), Psoriasis Disability Index,

Medical Outcomes Study 36-Item Short Form

and EuroQOL.

Of these, the DLQI is the

most widely used, despite it not being

specifically developed for psoriasis. The DLQI has been assessed in numerous psoriasis studies and is the easiest to use in clinical practice, due to its brevity and simplicity.

Assessing cardiovascular and metabolic risk in patients with psoriasis

Psoriasis is associated with an increased risk of cardiovascular disease (hypertension and heart failure), metabolic syndrome, diabetes and obesity compared with non-psoriatic skin diseases.

Psoriasis is an independent risk factor for coronary artery calcification, myocardial infarction and stroke.

Comorbidity is correlated with disease severity, with a higher prevalence of elevated serum insulin levels, obesity, diabetes and metabolic syndrome in patients with severe psoriasis compared with mild disease.

In a study of Tunisian patients with psoriasis, the prevalence of metabolic syndrome was significantly elevated in women with psoriasis (47% versus 30% in controls) and in all patients, after adjusting for age and gender.

A large, Middle Eastern study demonstrated an elevated risk of coronary heart disease, obesity, type 2 diabetes mellitus, hypertension, dyslipidaemia and metabolic syndrome, which increased with worsening psoriasis severity.

The association between psoriasis and increased risk of cardiovascular and metabolic disorders may be explained by the shared inflammatory component underlying these diseases.

Numerous immuno - logical factors involved in the pathogenesis of atherosclerosis have also been observed in psoriasis and other systemic inflammatory diseases.

The systemic inflammation that is typical of psoriasis is associated with increased levels

of highly sensitive C-reactive protein, elevated serum cytokines (including IL-6, IL- 17 and TNF- α ), and platelet hyperactivity.

When coupled with a metabolic disorder, such as obesity, the inflammatory cytokine signature found in psoriasis and abdominal adipose tissue may create a cycle of exacerbated and potentially synergistic inflammation that enhances the onset and severity of these comorbidities.

Under-recognition of the growing evidence for the systemic nature of psoriasis may have resulted in a patient population that is unaware of the increased risk of cardiovascular disease. Dermatologists are, therefore, increasingly advised to screen for cardiovascular and metabolic abnormalities prior to initiating treatment, as part of best practice for psoriasis management.

Management of PsA: early detection, prevention and reduction of joint damage

Psoriatic arthritis (PsA) is classified as a spondyloarthropathy, with characteristic features of synovitis, enthesitis, dactylitis and spondylitis.

The clinical course of PsA is variable and unpredictable. When untreated, the clinical profile is one of persistent inflammation, progressive joint damage, physical disability and increased mortality.

PsA occurs almost exclusively in the context of psoriasis, occurring in 6 – 39%

of psoriasis patients.

It is regarded as an

associated inflammatory disease of psoriasis,

and benefits from a shared-management

approach.

An example of such an

interdisciplinary management approach is

outlined in Fig. 1.

The mean time of

onset is 10 years following the first signs of

psoriasis, and manifestation of PsA does not

correlate with severity of psoriasis.

Similar

to psoriasis, PsA is associated with increased

Patient with psoriasis and psoriatic arthritis

Diagnostic Diagnostic

Assessment of disease activity SJC/TJC, DAS28, VAS

Assessment of disease activity PASI, BSA, PGA Interdisciplinary

treatment decision

Continuous interdisciplinary management

cardiovascular and metabolic risk, decreased QOL, increased work-related problems and increased utilization of healthcare resources.

Genetic, environmental and immuno - logical factors are implicated in the pathophysiology of PsA.

Immunological factors point to inflammatory mechanisms associated with a Th1 cell response;

cytokines produced by Th1 cells, including IL-2 and IFN- γ , are found in the synovial fluid of patients with PsA. In addition, TNF- α , IL-6 and IL-8, which are associated with cells of the innate immune response, are present in the synovial fluid and membranes of affected joints.

The chronic inflammatory mechanisms of psoriasis and PsA appear to share common immunopathological features and TNF- α

may be critical in driving the inflammatory process.

Psoriatic arthritis can be distinguished from other inflammatory arthritic diseases by its clinical and radiographic features, and is classified using the Classification Criteria for Psoriatic Arthritis (CASPAR).

PsA affects fewer joints than rheumatoid arthritis (RA) and lacks the typical symmetrical pattern of RA.

PsA should be suspected in patients with psoriasis who have stiffness on waking that lasts > 30 min, spinal stiffness that improves with exercise, joint swelling or tenderness, or dactylitis.

Nail dystrophy, scalp lesions and intergluteal/perianal psoriasis are also associated with an increased likelihood of PsA.

Ultrasound examination is useful for

detecting signs of inflammation and

FIGURE 1: Interdisciplinary management approach for patients with psoriasis and

psoriatic arthritis (SJC, swollen joint count; TJC, tender joint count; DAS28, Disease

Activity Score count in 28 joints;

VAS, visual analogue score;

PASI, Psoriasis

Area and Severity Index;

BSA, Body Surface Area;

PGA, Physician Global

Assessment

)

structural changes in joints and tendons of the fingers and toes of patients with psoriasis.

X-ray examination of hands and feet is important to detect PsA-typical erosions and/or osteoproliferation, and to differentiate PsA from other joint diseases such as osteo-arthritis. A variety of screening questionnaires may assist in early detection of PsA, including the Psoriasis Epidemiology Screening Tool, the Psoriatic Arthritis Screening and Evaluation tool and the Toronto Psoriatic Arthritis Screen.

The identification of PsA by dermatologists may assist in increasing accuracy and confidence in the diagnostic process.

Rheumatologists recommend that dermatologists ask patients with psoriasis about joint pain, morning stiffness, swelling and fatigue, and suggest that patients with signs of inflammatory joint disease, which is not relieved by non- prescription non-steroidal anti- inflammatory drugs, are referred to rheumatology specialists.

Although such referrals may be required, dermatologists often undertake the diagnosis and follow-up of these patients, employing tools such as CASPAR.

Greater collaboration between dermatologists and rheumatologists in this setting would undoubtedly help to improve patient management.

The early and appropriate systemic treatment of PsA may reduce disease progression and complications and should be considered in cases of moderate-to-severe disease.

Current treatment recommendations for psoriasis

Current treatment options for psoriasis include topical therapies, narrow- and broad-band ultraviolet B (UVB) phototherapy, oral psoralen plus ultraviolet

A (PUVA), traditional systemic agents and targeted biological therapies (namely, adalimumab, etanercept, infliximab and ustekinumab). A stepwise approach, based on disease severity, is recommended in many regional therapeutic recommendations for psoriasis management, including those from South Africa (Fig. 2).

International guidelines recognize a role for topical therapies, particularly in mild-to- moderate forms of psoriasis, where monotherapy or combination treatment with corticosteroids and vitamin D

analogues have shown good efficacy.

In the USA, the American Academy of Dermatologists (AAD) has published a comprehensive series of guidelines on the management of psoriasis and PsA.

These guidelines recommend that therapy should be tailored to the individual, with corticosteroids remaining the cornerstone of treatment.

Corticosteroids (with the exception of low- and mid-potency corticosteroids, where the evidence is weaker), vitamin D

analogues, tazarotene, combination of corticosteroid with either vitamin D

analogue or tazarotene, PUVA, and combination therapy with PUVA and topical agents have similar, high levels of recommendation. Combination therapy with topical agents and UVB is less highly recommended in the AAN guidelines.

When systemic therapy is indicated, methotrexate, cyclosporin A and acitretin are first-line options for clinicians in Africa and the Middle East.

Biological therapies are generally indicated for patients with psoriasis who have no, or poor, response to traditional systemic therapy after an adequate trial, or those with contraindications or intolerance to traditional systemic therapy.

Of the biological therapies, the TNF- α

inhibitors, etanercept and adalimumab, are

recommended by the AAD for the treatment of moderate-to-severe psoriasis and moderate-to-severe PsA, while infliximab is recommended for severe psoriasis and moderate-to-severe PsA.

Guidelines produced by the British

Association of Dermatologists consider patients with severe psoriasis to be eligible for biological therapy.

Severe psoriasis is defined as PASI or BSA score ≥ 10 with a DLQI score > 10, and at least one of the following criteria: (i) treatment with FIGURE 2: Current South African therapeutic recommendations for psoriasis (adapted from Raboobee et al.

and reprinted with permission from the South African Medical Journal under a Creative Commons Attribution – Non-commercial Works License;

UVB, ultraviolet B; PUVA, oral psoralen plus ultraviolet A; TNF- α , tumour necrosis factor- α ; IL, interleukin)

Mild

Moderate

Severe

Topical therapy

Phototherapy

Systemic therapy

UVB PUVA

Biological therapies

Corticosteroids Coal tar Dithranol Tazarotene

Vitamin D

analogues Tacrolimus

Combinations:

Corticosteroids plus salicylic acid

Corticosteroids plus vitamin D

analogues

Acitretin Cyclosporin A Methotrexate

T cell targeted biologicals:

Alefacept

Cytokine modulators:

TNF- α inhibitors Adalimumab Etanercept Infliximab

Ustekinumab Traditional

systemic therapy

IL-12/IL-23 antagonist

phototherapy and alternative standard systemic therapy are contraindicated or cannot be used due to the potential for treatment-related toxicity; (ii) intolerance or unresponsiveness to standard systemic therapy; (iii) the presence of significant unrelated comorbidities that preclude the use of systemic agents; and (iv) the presence of severe, unstable and life-threatening disease.

Recommended biological therapies include etanercept, adalimumab and infliximab; ustekinumab, an IL-12/IL-23 antagonist, is reserved for patients with severe psoriasis when TNF- α antagonist therapy has failed or is contraindicated.

The guidelines of the British National Institute for Health and Clinical Excellence (NICE) differ somewhat from those of the British Association of Dermatologists in that infliximab is recommended only for patients with very severe disease, defined as a PASI score ≥ 20 and DLQI score > 18.

NICE recommends etanercept, adalimumab and ustekinumab for use in patients with PASI ≥ 10 and DLQI > 10 (severe disease).

South African guidelines on the management of psoriasis were developed in 2010 by a working group of the Dermatological Society of South Africa.

These guidelines are based on, and broadly capture, the recommendations of current guidelines from the USA, UK, Germany, Canada and Finland, and adopt a pragmatic approach to account for regional differences.

For example, despite a lack of evidence supporting its efficacy, coal tar is recommended as a topical treatment in patients with mild psoriasis who require an inexpensive alternative to corticosteroids, vitamin D

analogues or tazarotene (Fig.

2).

In patients with moderate psoriasis, systemic PUVA or UVB have a similar level of recommendation. Traditional systemic therapy with cyclosporin A, methotrexate

and acitretin is the first-line treatment for patients with severe psoriasis (in order of strength of recommendation, strongest to weakest). Similar to other guidelines, the use of biological therapies (namely, etanercept, adalimumab or infliximab) is recommended for patients with severe disease following failure of traditional systemic therapy.

Systemic treatments, whether traditional or biological, are consistently indicated in those patients with moderate-to-severe psoriasis, generally defined as PASI, BSA or DLQI score ≥ 10.

First-line use of systemic therapies may be appropriate in a subset of patients with limited disease but debilitating symptoms, such as severe psoriasis affecting visible areas, the scalp or genitals, onycholysis or onychodystrophy of at least two fingernails, pruritus leading to scratching, and the presence of single recalcitrant plaques.

The initial efficacy of biological therapies

achieved during the induction phase

appears to be maintained or even improved

during long-term continuous treatment.

Data suggest that biological therapies have

efficacy and safety profiles that are suitable

for longer-term management of patients

with moderate-to-severe psoriasis, although

more definitive information on the long-

term safety and efficacy of these agents is

needed and should be obtained through

ongoing registries.

Early adequate

systemic treatment with an agent such as

methotrexate, followed by TNF- α inhibitor

therapy when indicated, may control the

immunological element of psoriasis

effectively, reducing the risk of

cardiovascular and metabolic

comorbidities.

Although current guidelines

do not specifically consider the role of TNF- α

inhibitors in reducing cardiovascular risk,

studies have shown that they can reduce

insulin resistance and other markers of

cardiovascular risk in psoriatic patients.

Experience from rheumatology confirms the beneficial effects of systemic therapy on cardiovascular risk.

In one study of 11 patients with RA, treatment with TNF- α inhibitors not only reduced symptoms but also improved endothelial function, suggesting an improvement in cardiovascular risk.

A retrospective analysis of data from the British Society for Rheumatology Biologics Register, evaluating the rate of myocardial infarction in 8670 patients with RA treated with anti-TNF- α therapy, showed a significant reduction in the risk of myocardial infarction among those who responded to anti-TNF- α therapy compared with non-responders.

The lack of recognition of the systemic nature of psoriasis may lead to situations where severe psoriasis is exclusively and inadequately treated with topical agents, without due consideration given to the patient’s cardiovascular and metabolic risk profile.

When clinicians, perhaps with limited dermatological experience, opt for a topical treatment approach in patients with moderate-to- severe psoriasis without marked improvement, it is reasonable to conclude that these patients are unlikely to receive maximum treatment-associated benefits and QOL improvements.

In cases of active PsA, moreover, systemic treatment approaches are essential to treat joint disorders appropriately and, in the case of TNF- α inhibitors, prevent irreversible joint damage.

Unmet needs in the

management of psoriasis in Africa and the Middle East

In the experience and opinion of the authors of the present article, the availability of new treatments and advances in the

understanding of psoriasis have resulted in successful efforts to optimize and streamline treatment management in Africa and the Middle East, particularly within individual centres and institutions. A major purpose of this review is to encourage this optimization process further at national and regional levels, since greater organization of practice and resources for the management of psoriasis will undoubtedly improve outcomes for patients living in these regions. The authors specifically discussed the current challenges and unmet needs in the management of psoriasis in Africa and the Middle East during a 1-day, face-to-face meeting in Johannesburg, South Africa, in February 2011. The results of this discussion are summarized below.

The panel agreed that more robust local

and regional epidemiological data are

required in order to describe the prevalence

and burden of psoriasis among diverse

African and Middle Eastern populations

more accurately. Small studies have provided

some information on the burden of psoriasis

in Africa and the Middle East, and indicate

that its prevalence is similar to that observed

in Western populations.

This insight would

be greatly enhanced by data from larger

epidemiological studies in the region, which

could also elucidate possible differences

between different ethnic groups. It is difficult

to convince healthcare providers to

implement changes to current management

practices without knowing the true size and

impact of the problem. The potential

genetically-mediated differences in clinical

presentation, complications and

consequences of psoriasis between the

various ethnic groups inhabiting the

African/Middle East region and Western

(Caucasian) populations have not yet been

fully explored and warrant further

investigation.

Despite the increasing recognition of psoriasis as a systemic disease with cardiovascular and metabolic comorbidities, this perception is not universal among physicians or patients in Africa and the Middle East, hampering the delivery of timely and adequate systemic therapy to patients with an indication for such treatment. This could be readily overcome with more effort in physician and patient education. It is important that patients are informed and educated about their disease, and its potential complications and comorbidities, in order for them to share the responsibility of management, particularly in terms of lifestyle choices and compliance with therapy.

It was determined that the relative cost of, and limited clinical experience with, topical agents and phototherapy may present a barrier to greater uptake of systemic therapy in Africa and the Middle East. Inadequate treatment, particularly of patients with more severe psoriasis, may be a worldwide problem. In European patients with severe psoriasis indicated for systemic therapy (cyclosporin A, methotrexate or PUVA), one study showed that only a minority actually received such treatment.

The cost–benefit of biological therapies in Africa and the Middle East can only be addressed by local pharmacoeconomic studies, taking into account the chronic, systemic nature of psoriasis, which has the potential to create a significant, long-term economic burden if inadequately treated. Data from Western studies suggest that biological therapies may be cost effective even in the short term,

and that the initial costs of anti-TNF- α treatment are partially offset by a reduction in healthcare requirements and increased productivity in the long term.

The uptake of biological therapies in Africa and the Middle East has been slower

than in more developed regions and there is, therefore, less clinical experience among dermatologists and other physicians in handling these agents. Countries such as South Africa have taken action to address this, providing hands-on training to dermatologists in the use of biological therapy – a practical training model that may be replicated elsewhere. The development of greater collaboration between dermatologists and rheumatologists in the treatment of psoriasis and PsA would substantially improve the care received by patients. While some dermatologists in Africa and the Middle East have limited experience with biological therapies, this is unlikely to be the case among their rheumatology counterparts, who use these agents routinely for the treatment of RA and other indicated rheumatological disorders.

Sharing knowledge and experience regarding the handling and use of biological therapies, which need not be a time- consuming process, would enable a partnership to be established between dermatologists and rheumatologists that could be maintained in the long term and prove to be mutually beneficial, for example, in the management of PsA.

The significant negative impact of psoriasis on QOL is widely recognized by dermatologists in Africa and the Middle East, but there is often a lack of priority given to the evaluation of QOL parameters as a treatment goal (compared with the assessment of skin severity and improvement), possibly due to the limited time available for patient consultation and follow-up. The under-recognition of the impact of QOL on psoriasis outcomes is not unique to Africa and the Middle East, but may also be a problem in Western countries.

In a group of 897 patients with plaque

psoriasis recruited from five European

countries, patients with poorer QOL were associated with increased healthcare resource utilization that was independent of disease severity, suggesting that QOL (in addition to skin disease severity) can predict economic disease burden.

Since improvements in QOL are known to have as much impact on the condition of the patient with psoriasis as improvements in topical signs and symptoms,

dermatologists may find that more attention given to QOL as a therapeutic target may improve the overall chance of treatment success.

In order to standardize current practices, the authors of this review agree that more formal, basic, local or regional guidelines are required for dermatologists regarding the management of psoriasis patients with concomitant PsA. Fostering an ongoing collaboration with rheumatologists would be particularly helpful in this setting.

Conclusions

Psoriasis is increasingly accepted as a complex, chronic, systemic disease. It is associated with a substantial negative impact on QOL and, in considerable numbers of patients, with extracutaneous signs and symptoms (PsA) and serious comorbidities (including cardiovascular disease and diabetes) that collectively contribute to a significant health and economic burden. As in other parts of the world, the management of psoriasis in Africa and the Middle East may not be optimal. An increase in physician and patient awareness and education on psoriasis, its complications, comorbidities and impact will improve this situation. Dermatologists and their allied healthcare professionals should be made aware of all available topical and systemic therapeutic options, and treat patients according to the current guideline recommendations, with the long-term aim of

delaying or preventing the development of complications or comorbidities. The individualization of treatment according to each patient’s disease profile should help to optimize treatment outcomes and reduce the burden of psoriasis.

Acknowledgements

The authors thank Dr Cathy Chow at UBM Medica Hong Kong for editorial/medical writing support, and Pfizer Africa and Middle East, Dubai, UAE, for providing funding to the inital working group meeting and editorial support.

Conflicts of interest

Dr M Abdulghani, Dr M Alkhawajah, Dr I

Benkaidali, Dr N Doss and Dr I Mokhtar

had no conflicts of interest to declare in

relation to this article. Dr A El Gendy was in

receipt of speaking and/or consulting

honoraria and research grants from

Gamgoom Pharma and Leo Pharma. Dr A

Al Sheik was in receipt of speaking and/or

consulting honoraria from Leo Pharma and

Galderma. Dr A Ammoury received

speaking and/or consulting honoraria or

payments from Pfizer, MSD, Abbott and

Janssen. Dr H Benchikhi received speaking

and/or consulting honoraria or payments

from GSK and MSD. Dr D Odendaal

received speaking and/or consulting

honoraria or payments from Bayer

Healthcare. Dr D Thaçi was in receipt of

speaking and consulting honoraria from

Abbott, Astellas, Biogen-Idec, Jansen-Cilag,

Novartis, Leo Pharma, MSD and Pfizer. Dr R

Weiss was an advisory board member for

MSD–Schering Plough, Abbott, GSK–Aspen

Stiefel and Adcock Ingram. Dr D Whitaker

received speaking honoraria from

Galderma and Astellas, and attended

advisory board meetings for Stiefel,

Schering Plough and Pfizer. Dr F Behrens

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• Received for publication 19 June 2011 • Accepted subject to revision 26 June 2011

• Revised accepted 13 September 2011 Copyright © 2011 Field House Publishing LLP received speaking and/or consulting

honoraria from Wyeth/Pfizer, Abbott, Roche, Chugai and MSD, and research grants from Roche and Wyeth/Pfizer. Dr N Raboobee was in receipt of speaking and/or consulting honoraria, was an advisory

board member and received research

funding from Schering Plough, Schering,

Abbott, Janssen, Pfizer, Astellas, Galderma,

Aspen, Stiefel and GSK. All of the above

declared conflicts of interest occurred in the

2 years prior to publication.

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Author’s address for correspondence Dr Magdy Abdulghani

Department of Dermatology, King Fahad Armed Forces Hospital, PO Box 9862, Jeddah 21159, Saudi Arabia.

E-mail: magdy1133@hotmail.com