الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
Psoriasis is an autoimmune, chronic, noncontagious, inflammatory skin disorder. The typical skin lesions of psoriatic patients are sharply demarcated erythematous plaques covered with silvery white lamellar scales. Psoriasis affects 3 –4% of people worldwide. The global incidence has increased in the last decades worldwide. It has variable and unpredictable manifestations that can severely affect a person’s physical and mental well-being, social life and ability to carry out normal daily activities.
To date, our knowledge about the etiology of psoriasis is still unclear and limited, genetic and environmental interaction was suggested. Few authors have evaluated the risk of psoriasis in patients exposed to potential environmental risk factors specifically heavy metals, whose effect on disease development should not be under-estimated.
Epidemiologic evidence suggested that increased risk with External and internal triggers, including mild trauma, sunburn, obesity, infections, smoking, high alcohol consumption, seasonal and hormonal changes, systemic drugs and stress might be responsible for psoriasis provocation. Less confirmed associations have been reported for exposure to heavy metals, as well as data regarding other environmental risk factors and obesity are inconclusive.
The present study was conducted at the Alexandria outpatient clinic at Alexandria Main University Hospital. Cases were psoriatic patients attending the dermatology outpatient clinic, and controls were healthy individuals matched to cases on age and sex.
The sample size was 60 subjects: 30 cases and 30 controls. A structured interviewing pre-designed questionnaire was administered to participants and was used to collect data from cases and controls. Data included: personal and socio-demographic data, medical history, lifestyle, dietary habits, indoor and outdoor environmental exposures.
A blood sample was drawn from each participant to measure the levels of cadmium, and chromium by flame atomic absorption spectrometry after wet digestion of the blood samples.
An educational program was performed every month for 3 months and PASI scoring was measured before and after the educational program to assess the changing in disease severity.
Appropriate statistical procedures were then applied to process the data, and the following results were obtained:
The median level of age when the disease began in cases was 43 years with a mean of (13- 55) years. The median duration of disease of studied case was 8 years with a mean of (1- 54) years. Twelve cases (40%) were on photo therapy. Eighteen cases (60%) were on methotrexate. There were also 20 cases (66.6%) with history of immune diseases.
There were 3 cases (10%) who experienced increase disease severity during pregnancy and lactation. Koebner’s phenomenon was positive in 11 cases (36.7%). Eight cases (26.7%) had increase in disease severity with increasing weight. There were 15 cases (50%) who experienced increased disease severity during winter, 5 cases (16.7%) increased disease severity during summer and 10 cases (33.3%) with no relation to weather.
Regarding the crowding index, there was a statistically significant higher crowding index in cases compared to controls (p ≤0.05).
With regard to family income, there was a statistically significant difference between cases and controls, there were 12 cases (40%) whom family income weren’t enough compared to 1control (3.3%). There were 16 cases (53.3%) and 16 controls (53.3%) with barely enough family income, Also there were 2 cases (6.7%) with enough family income compared to 13 controls (43.3%).
Regarding work, the current study found that people who were having office work were less liable to have psoriasis rather than those who were working in agriculture, industry, trading and other skilled work which may be due to lower exposure to environmental risk factors such as (high temperature, air pollutant, water pollutant and other physical, chemical and psychological stress factors).
It was also found that there was a statistically significant positive correlation between psoriasis and exposure to stress during work. Eighty percent of studied cases were exposed during work to psychological and nervous stress during work compared to 43.3 % of controls (OR = 5.231, 95% CI = 1.657 – 16.515), also 46.7% of cases were exposed to heavy physical activity during work compared to 16.7% of controls (OR = 4.375, 95% CI = 1.320 – 14.504), which may explain stress (physical, chemical and psychological) as an environmental risk factor for psoriasis.
There was a significant positive correlation (p ≤0.05) between exposure to high temperature, heavy metals and insecticide during work and predisposition to psoriasis.
A positive correlation (p ≤0.05) was found between smoking and psoriasis incidence, 40% of psoriasis patients were smokers compared to 8 % of controls (OR = 2.625, 95% CI = 0.838 – 8.211), also 20 % of cases were ex-smoker compared to 3.3% of controls (OR =10.50, 95% CI = 1.126 – 97.912), which may suggest smoking as an environmental risk factor of psoriasis.
There was also a significant positive correlation (p ≤0.05) between having household smokers and psoriasis incidence, 26.7 % of cases were having household smoker compared to 3.3 % of controls (OR = 10.545, 95% CI =1.227 – 90.662).
Shisha smoking was also found to have a significant positive correlation (p ≤ 0.05) with psoriasis, as 36.7 % of cases were smoking for shisha compared to 13.3% of controls. 83.3 % of cases were exposed to physical or psychological abuse compared to 13.3% of controls, which may be an indicator for the relation between stress and psoriasis.
The current study also reported a statistically significant positive correlation between smoking, having house hold smoker, shisha smoking, drinking alcohol or hashish and PASI scoring.
A positive correlation (p ≤0.05) was found between eating salty, spicy food or fish and psoriasis incidence. 63.3 % of cases were eating salty food compared to36.7% of controls, 83.3 % of cases were eating spicy food compared to 60 % of controls and 63.3% of cases were eating fish compared to 36.7 % of controls.
According to the present thesis, controls have less problems in drinking water compared to cases, as there were 40 % of controls having no water problems compared to 13.3 % of cases. The current study also found a positive correlation between having sewage rash, water problems and using cooker tubes and psoriasis.
Regarding the type of fuel, it was found that 36.7% of cases were using natural gas compared to 70 % of controls, also 63.3% of cases were using cooker tubes compared to 30 % of controls, which may explain a correlation between using cooker gas and psoriasis incidence.
Regarding residence, it was found that there was a significant positive correlation between living near garage, petroleum station, public transport stop or auto repair with psoriasis, as 56.7% of cases were living near these places compared to 20% of controls. The current study also found a significant positive correlation between living near places of collecting and burning garbage and psoriasis. 56.7% of cases were living near these places compared to 20% of control. Living near incinerator or land fill was found to have a relation with psoriasis as, 30% of cases were living near incinerator compared to 3.3% of controls. Also, living near mobile network booster station was found to have a relation with psoriasis as 40 % of cases were living near it compared to 16.7% of controls.
The PASI scoring of patients was ranging from (6.0 – 37.70) with Mean ± SD of (19.43± 8.62) and median of 20.0. There was a statistically significant difference between cadmium level in cases and controls. The mean level of cadmium in cases was (0.43 ± 0.69 mg/L), while in controls (0.04 ± 0.05 mg/L) (OR = 219.42, 95% CI = 0.262 - 183858.8). There was also a statistically significant difference between chromium level in cases and controls. The mean level of chromium in cases was (0.77 ± 0.50 0.52 mg/L), while in controls (0.49 ± 0.36 mg/L) (OR = 4.479, 95% CI = 1.252 – 16.026).
A multivariate stepwise logistic regression model was built in order to determine the importance of these factors in predicting psoriasis risk and the final model revealed that from eight risk factors tested, only two showed significant association with psoriasis. The risk was highest for subjects having blood cadmium levels >0.0188 mg/L with an OR of 7.302 (95% CI=1.004 – 53.127) followed by exposure to physical or psychological abuse or stress with an OR of 36.950 (95% CI =4.489– 304.122).
After performing the educational program every month for 3 months for the studied cases a significant positive relation (p ≤0.05) was found between the implementation of the educational program and improvement of the PASI scoring after educational program as the Mean ± SD of psoriatic cases before the educational program was 19.43 ± 8.62 with median of 20.0 (12.0 – 26.0) and has decreased to 15.37 ±8.28 with median of 15.0 (9.0 – 22.0).
It was also found that there was a significant positive correlation between improvement of the PASI scoring after educational program and systemic treatment, smoking reduction, stress reduction, weight reduction, wearing protective equipment and increase use of emollient. After, performing regression curve it was found that, systemic treatment and reduce exposure to stress were the most significant important factors in improvement of the PASI scoring.
In conclusion, it was evident from the results that psoriasis is multi-factorial in nature, where many risk factors interact and contribute to its development and that the need of increase patients’ awareness about the environmental risk factors and ways to avoid is a must and have a critical role in psoriasis treatment and prognosis.
5.2 Conclusion
from the present case control study, it is concluded that psoriasis is a multifactorial disease in which genetics and environmental risk factors play an important role and that the risk portion attributed to unsafe and unhealthy environment.
According to this study, it was found that psoriasis risk may increase during pregnancy(10 % of cases had increased disease severity during pregnancy), trauma (36.7 % reported the appearance of new psoriatic lesions during trauma), increasing weight (53.3% reported a relation between increase in body weight and psoriasis severity), winter weather 50 % of cases had increased disease severity during winter), increase crowding index as the median crowding index in cases was 2 compared to 1.42 in controls and decrease family income as There were 12 cases (40%) whom family income weren’t enough compared to 1 control(3.3%).
Regarding stress during work, 80 % of studied cases were exposed during work to psychological and nervous stress during work compared to 43.3 % of studied cases, also 46.7% of cases were exposed to heavy physical activity during work compared to 16.7% of controls which may explain stress (physical, chemical and psychological) as an environmental risk factor for psoriasis.
As regard to smoking, there were 40 % of cases were smokers compared to 8 % of controls, 26.7 % of cases were having household smoker compared to 3.3 % of controls.
Also it was found that 63.3 % of cases were eating salty food compared to 36.7% of controls, 40 % of controls having no sanitary water problems compare to 13.3 % of cases, there were also 26.7% of cases having sewage rash compare to 3.3 % of controls also, 63.3% of cases were using cooker gas tubes compared to 30 % of controls.
Regarding residence, it was found that 56.7 % of cases living near garage, petroleum station, public transport stop or auto repair with psoriasis compared to 20 % of controls who were living near these places, 30 % of cases were living near incinerator compared to 3.3 % of controls, 40 % of cases were living near mobile network booster compared to 16.7 % of controls were found.
According to the current study, the mean level of cadmium in cases was (0.43 ± 0.69 mg/L), while in controls (0.04 ± 0.05 mg/L). The mean level of chromium in cases was (0.77± 0.50 mg/L), while in controls (0.49 ± 0.36 mg/L).
A multivariate stepwise logistic regression model revealed that from eight risk factors tested, only two showed significant association with psoriasis. The risk was highest for subjects having blood cadmium levels > 0.0188 mg/L with an OR of 7.302 (95% CI=1.004– 53.127) followed by exposure to physical or psychological abuse or stress with an OR of 36.950 (95% CI =4.489– 304.122).
After performing an educational program every month for 3 months about the importance of decrease exposure to environmental risk factors, Mean ± SD of PASI scoring had decreased from 19.43 ± 8.62 with median of 20.0 (12.0 – 26.0) to 15.37 ± 8.28 with median of 15.0 (9.0 –22.0). After performing regression curve it was found that, systemic treatment and reduce exposure to stress were the most significant important factors in the improvement of the PASI scoring
In conclusion, environmental exposures may contribute to the initial break in immune tolerance resulting in autoantibody formation and to the subsequent progression to clinical manifestations over time. This emphasizes the urgent need for interventions to reduce environmental risk factors exposure and raise public awareness.
5.3 Recommendations
In light of the results of the present study, the following recommendations are suggested to help decrease psoriasis risk:
At individual level
• Increasing the awareness of patients about the environmental pollutants and the ways to protect their health.
• Increasing the awareness of health care providers about environmental risk factors, so they can advise the patients about the ways of reduction of exposure to environmental hazards.
At local community level
• Educational awareness programs to patients and their family should be carried out in any possible public places to raise their knowledge about environmental hazards and how to minimize the sources of their exposure and their consequent negative impacts.
At country level
• Policies, regulations and possible control measures to prevent over exposure to heavy metals so that the blood levels of these heavy metals do not exceed the permissible range.
• Considerable governmental effort is recommended to decrease environmental pollution through elimination and reduction of the source of pollution, and consequently reduction of the effect of environmental risk factors on disease occurrence.
• Regular monitoring of heavy metals and chemicals used in the manufacture of cosmetics products which may cause health risks to users.
Future researches
• Additional experimental and epidemiological studies are required to determine the causative role of several environmental exposures, to confirm data from case control studies. Additionally, the combinatory effects of genetic susceptibility with non- genetic factors need to be addressed.
• More research should be geared towards finding a possible cause, a cure, and more effective treatment plans and strategies to extend and increase the quality of life for psoriatic patients.
• New studies to establish new cut off points of heavy metals in the human body above which one should act to reduce their levels before the appearance of obvious side effects.