10.5826/dpc.1303a209
Introduction: Sexual relationships are an integral part of females psychological and physiological wellbeing.
Objectives: The study aimed to identify prevalence and impact of Female Sexual Dysfunction (FSD) in women affected with psoriasis.
Methods: This cross-sectional study was carried out on 150 married females who were interviewed to answer Female Sexual Function Index (FSFI) questionnaire and were divided into two groups: the first group included 100 female patients complaining of psoriasis (50 suffering from moderate psoriasis and 50 with severe psoriasis). The disease severity was graded according to the Psoriasis Area and Severity Index (PASI) while the second group included 50 age matched women who served as controls.
Results: Female sexual dysfunction (FSD) in psoriasis female groups was higher than that in the control group (47%, 24%, P &lt; 0.05). The mean total scores of FSFI ranged from 12.30 to 34.20 and were significantly lower in the severe PASI affected group (22.34 ± 5.35) when compared to moderate PASI group (26.24 ± 2.67) or control group (28.79 ± 2.22). In addition, total scores were significantly lower among moderate PASI affected females when compared to control group.
Conclusions: Sexual dysfunction should be routinely investigated in female patients with psoriasis in the case of moderate-severe disease due to its negative impact on quality of life. Further research over the effect of certain interventional programs on FSD should be considered for patients suffering from psoriasis.
text/xml
2160-9381
3235
en
Yasmin El Zawahry
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
female
Prevalence of Female Sexual Dysfunction among Psoriatic Females: a Cross Sectional Case Controlled Study  
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2023-07-31
2023-02-10
2023-07-31
2023-08-24
e2023209
Dermatol Pract Concept
Introduction: Sexual relationships are an integral part of females psychological and physiological wellbeing.
Objectives: The study aimed to identify prevalence and impact of Female Sexual Dysfunction (FSD) in women affected with psoriasis.
Methods: This cross-sectional study was carried out on 150 married females who were interviewed to answer Female Sexual Function Index (FSFI) questionnaire and were divided into two groups: the first group included 100 female patients complaining of psoriasis (50 suffering from moderate psoriasis and 50 with severe psoriasis). The disease severity was graded according to the Psoriasis Area and Severity Index (PASI) while the second group included 50 age matched women who served as controls.
Results: Female sexual dysfunction (FSD) in psoriasis female groups was higher than that in the control group (47%, 24%, P &lt; 0.05). The mean total scores of FSFI ranged from 12.30 to 34.20 and were significantly lower in the severe PASI affected group (22.34 ± 5.35) when compared to moderate PASI group (26.24 ± 2.67) or control group (28.79 ± 2.22). In addition, total scores were significantly lower among moderate PASI affected females when compared to control group.
Conclusions: Sexual dysfunction should be routinely investigated in female patients with psoriasis in the case of moderate-severe disease due to its negative impact on quality of life. Further research over the effect of certain interventional programs on FSD should be considered for patients suffering from psoriasis.
Yasmin El Zawahry
2023/07/31
10.5826/dpc.1303a209
e2023209
Department of Dermatology, Medical Research and Clinical Studies Institute, National Research Centre, Egypt
2160-9381
female
en
e2023209
Shah SFH, Merchant SA, Shah SA. Female sexual dysfunction in psoriasis: a systematic review and meta-analysis using the Female Sexual Function Index. Int J Impot Res. 2022. DOI: 10.1038/s41443-022-00650-9. PMID: 36456639.
Prevalence of Female Sexual Dysfunction among Psoriatic Females: a Cross Sectional Case Controlled Study  
https://dpcj.org/index.php/dpc/article/download/3235/2119
      Prevalence of Female Sexual Dysfunction
    Among Psoriatic Females: A Cross Sectional Case
                   Controlled Study
      Mohamed L. Elsaie1, Noha S. Hanafy1, Sherief M. Hussein1, Ola O. Abou Zeid1,
    Mohamed S. Zaky2, Ramadan M. Eldahshan2, Hesham A. Nada3, Osama Sayedahmed2,
                                Yasmin B. El Zawahry1


1 Department of Dermatology, Medical Research and Clinical Studies Institute, National Research Centre, Egypt
2 Department of Dermatology, Venereology and Andrology, Damietta Faculty of Medicine, Al-Azhar University, Egypt
3 Department of Dermatology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt



Key words: Female sexual dysfunction, Marriage, Psoriasis, Female, Autoimmune
Citation: Elsaie ML, Hanafy NS, Hussein SM, et al. Prevalence of Female Sexual Dysfunction among Psoriatic Females: A Cross Sectional
Case Controlled Study. Dermatol Pract Concept. 2023;13(3):e2023209. DOI: https://doi.org/10.5826/dpc.1303a209
Accepted: March 23, 2023; Published: July 2023
Copyright: ©2023 Elsaie et al. This is an open-access article distributed under the terms of the Creative Commons
Attribution-NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted
noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing Interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding Author: Mohamed L. Elsaie, MD, Department of Dermatology, NRC, Egypt. ORCID : 0000-0001-7541-5241
Tel: +201099501169 Email: Egydoc77@yahoo.com




  ABSTRACT             Introduction: Sexual relationships are an integral part of females psychological and physiological
                       wellbeing.
                       Objectives: The study aimed to identify prevalence and impact of Female Sexual Dysfunction (FSD)
                       in women affected with psoriasis.
                       Methods: This cross-sectional study was carried out on 150 married females who were interviewed
                       to answer Female Sexual Function Index (FSFI) questionnaire and were divided into two groups: the
                       first group included 100 female patients complaining of psoriasis (50 suffering from moderate psoria-
                       sis and 50 with severe psoriasis). The disease severity was graded according to the Psoriasis Area and
                       Severity Index (PASI) while the second group included 50 age matched women who served as controls.
                       Results: Female sexual dysfunction (FSD) in psoriasis female groups was higher than that in the con-
                       trol group (47%, 24%, P < 0.05). The mean total scores of FSFI ranged from 12.30 to 34.20 and were
                       significantly lower in the severe PASI affected group (22.34 ± 5.35) when compared to moderate PASI
                       group (26.24 ± 2.67) or control group (28.79 ± 2.22). In addition, total scores were significantly lower
                       among moderate PASI affected females when compared to control group.




Original Article | Dermatol Pract Concept. 2023;13(3):e2023209                                                                          1
                      Conclusions: Sexual dysfunction should be routinely investigated in female patients with psoriasis in
                      the case of moderate-severe disease due to its negative impact on quality of life. Further research over
                      the effect of certain interventional programs on FSD should be considered for patients suffering from
                      psoriasis.




Introduction                                                       Methods
Psoriasis is a chronic condition that impacts self-perception      This cross-sectional study was approved by the ethical com-
of oneself. Psychological evaluation is of extreme impor-          mittee and study review board. After consideration, one
tance to identify to what extent psoriasis may influence           hundred and fifty married women were recruited into two
sexual health and to what extent patients are susceptible to       groups to answer Female Sexual Function Index (FSFI) ques-
psychiatric disorders [1,2].                                       tionnaire over a period from January 2022 to October 2022.
    Psoriasis and Psoriatic arthritis are multifactorial chronic   Group 1 included 100 females diagnosed with psoriasis at-
disorders whose etiopathogenesis essentially derive from the       tending for consultation or regular follow ups at the outpa-
alteration of several signaling circuits that affect the func-     tient clinic and the second control group (group 2) included
tional and structural property of the skin. In fact, the mod-      50 women not suffering from psoriasis; recruited from hos-
ulation of expression profiles of KRTs in keratinocytes and        pital staff or attendants with patients at different hospital
the consequent alteration of cell‐cell and cell‐matrix interac-    clinics and who served as controls. Recruited females for the
tions (in which COLs play a fundamental role) contributes          study were instructed and explained the study procedures
to the hyperproliferation of keratinocytes, enhancement of         and signed an informed consent before starting of the study.
immuno‐inflammatory responses with over‐production of                 Subjects were eligible for inclusion if were females, were
cytokines by Th1 and Th17 cells, which, ultimately, lead to        18-40 years old, were married for at least 1 year, and have
the dysregulation of epidermis homeostasis [3,4].                  had a stable marital relationship. As for the psoriatic group,
    Finding of psychiatric morbidity in patients with Psori-       female patients aged 18-40 and with moderate-to-severe
asis can be explained by the associated stigma which is fre-       plaque psoriasis vulgaris defined as body surface area (BSA)
quently experienced by patients. Stigmatization in psoriasis       affected ≥ 10% were included. Those with records of mastec-
and experiencing social rejection and avoidance for fear of        tomy, oophorectomy, pregnancy or suffering from any gyne-
infection or filth is common and rather affects and devas-         cological disorders or on an ongoing course of psychotropic
tates patients quality of life (QoL). This leads to social em-     medications were excluded. Moreover, those giving history
barrassment, withdrawal and low social interactions [5].           of a sexual disorder among their spouses were excluded.
    Studies have compared the effects of psoriasis on
QoL to that of major diseases like cancer and depression.          Study Procedures
Self-perception and self-acceptance as a desirable human           All participants underwent the following:
being are significantly distorted among psoriatic patients
which negatively impacts all aspects of life [6,7].                1. History Taking
    Egyptian community is conservative in nature and the                  Patients data including age, body mass index (BMI),
topic of sexuality in general remains to be a taboo in many           educational level, onset, course and duration of psoriasis,
communities and data related to sexual health and dysfunc-            past history of any medications used and durations of use
tion or its prevalence remains to be under reported. Previous         were all identified. Moreover, family history of psoriasis
studies reported sexual dysfunction to range between 52.8%            and associated comorbidities (metabolic syndrome, hy-
and 76.9% among Egyptian females [8-10].                              pertension, diabetes) were all recorded if any.
                                                                   2. Filling out the Female Sexual Function Index (FSFI)

Objectives                                                            Questionnaire
                                                                          Participant females were interviewed privately and
The scarcity and rarity of studies identifying the impact of          confidentially by a female investigator using the and Ar-
psoriasis on sexual health of Egyptian females led us to per-         abic translated and validated 19- item structured FSFI
form this cross-sectional observational study to evaluate the         questionnaire [11-13].
frequency and associated factors of FSD in Egyptian women                 The FSFI uses six item separate domains to assess sex-
suffering from psoriasis.                                             ual functioning in women (desire, arousal, lubrication,



2                                                                      Original Article | Dermatol Pract Concept. 2023;13(3):e2023209
    orgasm, satisfaction, pain) with a total score of 26.5 de-          Results
    termined as the cutoff score to distinguish between nor-
    mal and abnormal sexual dysfunction.                                Socio-Demographic and Metabolic Characteristics
3. Calculating Psoriasis Area Severity Index (PASI)                     In the present study, female patient ages ranged from 18 to
         To calculate PASI, the body was divided into four ar-          40 years with a statistically significant increase of age among
    eas (head (H) (10% of a person’s skin); arms (A) (20%);             severe PASI patients (33.51 ± 2.08) when compared to ei-
    trunk (T) (30%); legs (L) (40%). By adding up each areas            ther moderate PASI group (26.32 ± 6.01) or control group
    score a final PASI value is reproduced with a maximum               (29.84 ± 6.09). No significance in age was determined be-
    value of 72 which means a 100% body involvement.                    tween moderate PASI females and (P = 0.38) (Table1).
    Scores below 10 mark mild psoriasis and scores above                BMI increased significantly among severe PASI psoriatic
    20 are regarded as severe while scores falling between              patients (29.12 ± 2.76) when compared to either moderate
    10 and 20 are regarded as moderate psoriasis. In the cur-           PASI patients (26.63 ± 2.87) or control group (23.97 ± 1.39).
    rent cross-sectional study, only females aged 18-40 with            On the contrary a significant decrease in BMI was observed
    moderate to severe plaque psoriasis (BSA ≥ 10%) were                among moderate PASI females when compared to controls
    included.                                                           (Table 1).
                                                                           Disease duration in females suffering from psoriasis
Statistical Analysis                                                    ranged from 1 to 27 years and was significantly less in mod-
Statistical package for social sciences (SPSS) 26 was used              erate PASI females when compared to those with severe PASI
for providing, mean SD of quantitative data and categori-               (3.51 ± 2.52 versus 13.12 ± 6.17 respectively; P < 0.001).
cal data. Kruksal-Wallis and Mann-Whitney tests were used                  Psoriasis patients age at disease onset ranged from 14
for non-parametric data and linear regressions were iden-               to 39 years and was significantly lower among severe PASI
tifies. P values of less than 0.05 were reported statistically          group when compared to moderate PASI and control group
significant.                                                            (P < 0.001).




                              Table 1. Demographic characteristics of studied subjects.
                                                                   Age
                                                 Mean            SD          Minimum             Maximum               P values
 Moderate PASI                                   26.32           6.01          18.00                40.00
 Severe PASI                                     33.51           2.08          28.00                40.00             P1<0.001
                                                                                                                      P2 = 0.48
 Control                                         29.84           6.09          18.00                40.00
                                                                                                                      P3 <0.001
 Total                                           30.57           6.00          18.00                40.00
                                                                   BMI
                                                 Mean            SD          Minimum             Maximum               P values
 Moderate PASI                                   26.63           2.87          21.40                32.90
 Severe PASI                                     29.12           2.76          25.50                37.40             P1<0.001
                                                                                                                      P2 <0.001
 Control                                         23.97           1.39          20.40                27.05
                                                                                                                      P3< 0.001
 Total                                           27.03           3.25          20.40                36.98
                                                           Disease Duration
                                                 Mean            SD          Minimum             Maximum                   P
 Moderate PASI                                     3.51          2.52           1.00                11.00
 Severe PASI                                     13.12           6.17           4.00                27.00               < 0.001
 Total                                             8.09          6.66           1.00                27.00
                                                          Age at disease onset
                                                 Mean            SD          Minimum             Maximum                P value
 Moderate PASI                                   29.06           4.41          29.00                39.00
 Severe PASI                                     21.75           2.34          14.00                36.00               <0.001
 Total                                           22.13           7.34          14.00                39.00

BMI = body mass index; PASI = Psoriasis Area and Severity Index; SD = standard deviation.




Original Article | Dermatol Pract Concept. 2023;13(3):e2023209                                                                       3
Prevalence and Types of FSD                                            was significantly decreased arousal among moderate PASI
Desire scores ranged from 1.27 to 6 and were significantly             females when compared to control group (P < 0.05).
lower in those with severe PASI (3.42 ± 1.27) when com-                     Lubrication decreased significantly among those with se-
pared to either those with moderate PASI or controls (4.23 ±           vere PASI (3.14 ± 0.79) when compared to moderate PASI
0.64 and 4.99 ± 0.59, respectively) (Table 2).                         group or controls (3.82 ± 0.69; 4.29 ± 0.64 respectively)
    Arousal scores ranged from 1.46 to 5.38 and were sig-              and was significantly decreased in those with moderate PASI
nificantly lower in those with severe PASI (3.49 ± 1.03) when          when compared to controls.
compared to either those with moderate PASI or controls                     Orgasm decreased significantly among those with severe
(4.47 ± 0.42 and 4.94 ± 0.59, respectively). In addition, there        PASI (3.50 ± 0.98) when compared to moderate PASI group




                         Table 2. Female Sexual Function Index domain and total scores.
                                                                  Desire
                                Mean         SD        Minimum         Maximum                                P values
 Moderate PASI                   4.23       0.64         2.45               5.48                            P1 < 0.001
 Severe PASI                     3.42       1.27         1.27               4.89                            P2 < 0.001
 Control                         4.99       0.59         3.67               6.00                            P3 < 0.001
                                                                  Arousal
                                Mean         SD        Minimum         Maximum                                P value
 Moderate PASI                   4.47       0.42         3.25               5.38
 Severe PASI                     3.49       1.03         1.46               4.69              P1 < 0.001*P2 = 0.001*P3 <0.001*
 Control                         4.94       0.59         3.68               5.73
                                                                Lubrication
                                Mean         SD        Minimum         Maximum                                P value
 Moderate PASI                   3.82       0.69          2.3               5.17                            P1 < 0.001
 Severe PASI                     3.14       0.79         1.47               4.24                            P2 <0.001
 Control                         4.29       0.64         3.50               5.69                            P3 = 0.006
                                                                  Orgasm
                                Mean         SD        Minimum         Maximum                                P values
 Moderate PASI                   3.99       0.77         2.30               5.10                            P1 = 0.007
 Severe PASI                     3.50       0.98         1.60               4.60                            P2 < 0.001
 Control                         4.42       0.58         2.80               5.80                            P3 = 0.017
                                                                Satisfaction
                                Mean         SD        Minimum         Maximum                                P value
 Moderate PASI                   5.19       0.40         4.10               5.50                           P1 = 0.90(ns)
 Severe PASI                     5.08       0.67         3.20               5.40                           P2 = 0.75(ns)
 Control                         5.14       0.32         4.30               6.00                           P3=0.86 (ns)
                                                   Dyspareunia (painful intercourse)
                                Mean         SD        Minimum         Maximum                                P values
 Moderate PASI                   4.61       0.55         3.50               6.00                            P1 <0.001
 Severe PASI                     4.88       0.68         3.20               6.00                            P2 < 0.001
 Control                         3.94       0.97         1.70               5.20                            P3 = 0.007
                                                                Total score
                                Mean        S. D       Minimum         Maximum                                P value
 Moderate PASI                  26.24       2.67          20                29.70                           P1 < 0.001
 Severe PASI                    22.34       5.35         12.30              28.30                           P2 < 0.001
 Control                        28.79       2.22         22.30              34.20                           P3 = 0.015

FSD = female sexual dysfunction; ns = not significant; PASI = Psoriasis Area and Severity Index; SD = standard deviation.




4                                                                              Original Article | Dermatol Pract Concept. 2023;13(3):e2023209
            Table 3. Incidence and prevalence of female sexual dysfunction in the studied groups.
                                   Incidence of female sexual dysfunction in studied groups
                                           Moderate PASI                    Severe PASI                    Control            Total
                                             N             %            N             %                N           %    N             %
 FSD          Positive (< 26.55)             18         36.0%          29           58.0%          12           24.0%   59         39.3%
              Negative                       32         66.0%          21           42.0%          38           76.0%   91         60.7%
 P values                                                            P1 = 0.008; P2 = 0.013, P3 <0.001
                                 Prevalence of FSD among psoriatic patients versus controls
                                                  Psoriatic (100)                      Control group (50)
                                                    N                  %               N                     %               P value
 FSD          FSD (<26.55)                         47                 47.0            12                   24.0%
              No FSD                               53                 53.0            38                   76.0%            < 0.001*
 Risk estimate                                          Odds ratio = 1.33, 95% CI (1.16- 1.52)

CI = confidence interval; FSD = female sexual dysfunction; PASI = Psoriasis Area and Severity Index.




or controls (3.99 ± 0.77 and 4.42 ± 0.58, respectively) and                    Table 4. Logistic regression analysis for
was significantly decreased in those with moderate PASI                           prediction of sexual dysfunction.
when compared to controls.
                                                                              Predictors                    β                  P
    Satisfaction scores showed no significant difference among
                                                                        Age                                -1.76              0.78
all study groups despite being lower among psoriatic patients.
                                                                        Duration                            0.27              0.04
    Dyspareunia was significantly reduced in control group
                                                                        Psoriasis severity                 17.89            < 0.001
(3.94 ± 0.97) when compared to Severe PASI group (4.88 ±
0.68) or moderate PASI group (4.61 ± 0.55). In addition,
pain score was insignificantly lower in moderate PASI pa-              showed significant associations, none of them showed to be
tients when compared to the severe PASI group.                         a risk factor for FSD (P = 0.78 and P = 0.64, respectively),
    Considering the total FSFI score which ranged from                 while psoriasis severity and its duration were risk factors for
12.30 to 34.20, a significant reduction was observed among             development of FSD in the studied females (P < 0.001 and
severe PASI females (22.34 ± 5.35) when compared to ei-                P = 0.04, respectively) (Table 4).
ther moderate PASI patients or controls (26.24 ± 2.67 and
28.79 ± 2.22, respectively) and in moderate PASI females
                                                                       Conclusions
when compared to the control group.
    Female sexual dysfunction determined by a cutoff score             Sexual health is essential for physical and psychological
< 26.55 was significantly higher in patients with severe PASI          well-being. A number of factors had been related to sexual
(58.0%) when compared to moderate PASI patients or con-                dysfunction among patients suffering from psoriasis, yet the
trol group (36.0% and 24.0%, respectively). In addition,               exact mechanism remains to be fully elucidated [4,5].
there was significant increase of FSD among moderate PASI                    In our study model using FSFI, we identified the prev-
patients compared to controls (Table 3).                               alence of sexual dysfunction to be significantly higher in
                                                                       both severe and moderate PASI groups (52.0 and 30.0%,
Risk Factors for FSD                                                   respectively) than in the control group (10%). This finding is
Psoriasis regardless of its severity (odds ratio 1.33;                 consistent with results obtained by Nassar et al. who found
CI 1.16-1.52) significantly affected 47.0% of females com-             the prevalence of FSD to be higher among psoriatic females
pared to 24.0% among controls and was determined a risk                than controls and determined the existence of a correlation
factor for FSD.                                                        between psoriasis severity and FSD [15].
    Patients complaining of FSD had a significantly earlier                  A major systemic literature review of sexual dysfunction
disease onset with longer duration when compared with nor-             in patients with psoriasis, psoriatic arthritis as well as rheu-
mal controls while BMI showed no significant correlation.              matoid arthritis assessed 1472 females with ages ranging
    Running logistic regression to examine if any of signif-           from 23 to 62 years and found prevalence rates in all studies
icant associations is a risk factor when considering all fac-          to vary from 22.6% to 71.3%. An Italian multicenter case
tors together, age, and age of onset of psoriasis, although            control study demonstrated a higher prevalence of sexual



Original Article | Dermatol Pract Concept. 2023;13(3):e2023209                                                                             5
dysfunctions in moderate-severe psoriatic patients aged be-             A recent metanalysis of eight studies including 563
low 46 years when compared to healthy controls [16].                women with psoriasis and 525 controls identified signifi-
    In the present study, the prevalence of sexual dysfunction      cantly impaired sexual function in women with psoriasis
in the control group (24.0%) is slightly lower than the values      compared to controls, suggesting that routine assessment of
found in other studies with healthy Egyptian women, where           sexual health may be beneficial [31].
prevalence varied from 30% to 34.7%. This could be explained            Identifying and communication about a subject histori-
by the different epidemiological profiles of the study groups       cally regarded a taboo in middle eastern culture is a major
and the fact that women with chronic diseases, except for ar-       strength of this study. The only reliance on a questionnaire
thritis, or chronic drug use were not excluded [17,18]. Sexual      and lack of hormonal or clitoral doppler sonography in a
difficulties among different ethnic groups can be related to dif-   limited population sample is a limitation to the current study.
ference in culture, habits as well as religious attitudes. In our       Sexual health and dysfunction and their impact on qual-
Egyptian community, the conservative beliefs and traditions can     ity of life should be part of the integral routine investigation
influence discussing sexual problems openly and could result        for females complaining of psoriasis. Further research over
in underreporting the existence of any especially among rural       the effect of certain interventional programs on FSD should
communities due to perceived cultural and religious restraints.     be considered for patients suffering from psoriasis. Larger
    We demonstrated a significant difference between psori-         multicenter studies investigating the sexual well-being of fe-
asis group and control group regarding desire, arousal, lu-         males affected by chronic conditions should be considered
brication, orgasm, satisfaction and pain domain scores. This        for better assessment and understanding how such condition
comes in agreement with a number of studies that demon-             could impact and hinder their quality of life and provide in-
strated significant sexual dysfunction affection among all          sights on how to alleviate any dysfunctions.
domains in psoriatic patients [19-22]. This was in contrary
to Khaled et al. who reported no significant difference be-
tween psoriasis group and control group regarding desire,           References
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Original Article | Dermatol Pract Concept. 2023;13(3):e2023209                                                                                     7
