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ORIGINAL ARTICLE
Year : 2011  |  Volume : 56  |  Issue : 6  |  Page : 694-699
Pilot study of sexual dysfunction in patients with psoriasis: Influence of biologic therapy


1 FEA Dermatología, Complejo Hospitalario de Jaen, Jaen, Spain
2 FEA Medicina Interna, Hospital Santa Ana, Motril, Granada, Spain
3 EU Ciencias de la Salud, Granada, Spain

Date of Web Publication14-Jan-2012

Correspondence Address:
Ricardo Ruiz-Villaverde
Emir 15 Bloque 4 Portal 1 3ºG, 18006 Granada
Spain
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5154.91831

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   Abstract 

Background: Psoriasis is a chronic skin disease that affects 1 to 3% of the population in most industrialized countries. It is commonly associated with a variety of psychological problems including low self-esteem, depression, suicidal thoughts, and sexual dysfunction. Materials and Methods : We have performed a pilot study in which we have tried to assess the impact on sexual dysfunction in patients with psoriasis who have started treatment with biological therapy using validated indexes in Spanish: International Index of Erectile Function for men and female sexual function index in women. Results : Considering the men and women from our study, an improvement in FSFI by an average of 9.5 and 6.3 points is observed, respectively. Conclusion: We considered our series as a first step for a more detailed approach to the study of sexual function in patients with psoriasis.


Keywords: Biological therapy, psoriasis, sexual dysfunction


How to cite this article:
Ruiz-Villaverde R, Sánchez-Cano D, Ramirez Rodrigo J, Villaverde Gutierrez C. Pilot study of sexual dysfunction in patients with psoriasis: Influence of biologic therapy. Indian J Dermatol 2011;56:694-9

How to cite this URL:
Ruiz-Villaverde R, Sánchez-Cano D, Ramirez Rodrigo J, Villaverde Gutierrez C. Pilot study of sexual dysfunction in patients with psoriasis: Influence of biologic therapy. Indian J Dermatol [serial online] 2011 [cited 2020 Jul 12];56:694-9. Available from: http://www.e-ijd.org/text.asp?2011/56/6/694/91831



   Introduction Top


Our daily clinical practice is becoming more common to complement the clinical aspects of the patients with a systematic assessment of their subjective perception about their disease. Undoubtedly, the availability of validated instruments for Spanish population (general and specific) to measure these psychological aspects in the most prevalent chronic diseases is a great contribution. Psoriasis is a chronic skin disease that affects 1 to 3% of the population in most industrialized countries. It is commonly associated with a variety of psychological problems including low self-esteem, depression, suicidal thoughts, and sexual dysfunction. These items, along with the impact related to body surface area affected, and psoriasis co-morbidities make from psoriasis, one of the states with the greatest impact on quality of life of patients suffering it, as has already been studied and published. [1] One of the aspects related to quality of life is the sexual dysfunction. [2] It is also one of the items included in the main index that evaluates the quality of life in dermatological patients (Dermatology life quality index). The introduction of biological therapies have revolutionized the management of patients with psoriasis and increased their quality of life, including sexual dysfunction problems.

In this pilot study, we have tried to assess the impact on sexual dysfunction in patients with psoriasis who have started treatment with biological therapy using validated indexes in Spanish: International Index of Erectile Function (IIEF) for men [3],[4] and female sexual function index (FSFI) in women. [5],[6]


   Materials and Methods Top


Study population

We have evaluated 20 patients, 10 men and 10 women with moderate to severe psoriasis with BSA (Body surface area) over 10, PASI (psoriasis activity skin index) over 10, with poor tolerance or contraindication to systemic therapy which were going to begin biological treatment (seven men and seven women under etanercept treatment, and three men and three women under adalimumab treatment). None of the patients had been treated with acitretin, but with methotrexate or cyclosporine. Previously to the introduction of the biological therapy, all patients were just with topical treatment for 1 month, during which we applied for our routine protocol (blood count, biochemistry, urinalysis, serology for hepatitis viruses and HIV, CXR-chest X-ray, and TST-tuberculin skin test).

Those patients who had a sexually active couple were included; meanwhile, patients with pulmonary, hepatic, hematological, renal, or endocrine diseases (thyroid disease and diabetes mellitus) or under anxiolytic or antidepressant medications that may interfere with their sexual life were excluded from our study (None of our patients had a clinical diagnosis of depression). In female patients, we requested a hormone study pituitary-gonadal axis to rule out associated pathology. Considering that our study is a pilot one, we have enrolled a small number of patients. They have been included consecutively if they met the selection criteria previously reported.

Recruitment period have been extended for one year. Regarding male patients, IIEF questionnaire was used to assess sexual function (Appendix A). It was filled at baseline and at 6 months from the beginning of the treatment. Patients selected for the study had met all the PASI 75 (regardless of the biological agent used) and had not experienced adverse events that led to suspension of treatment. The results are presented as mean with corresponding Standard Deviation (confidence interval 95%). We have used student t test in order to compare the mean΄s differences with P value <0.05.

IIEF has an adequate sensitivity and specificity. It has been translated and validated to Spanish. [4] It is composed of 15 questions that assess the following five aspects in the last four weeks: erectile function, orgasmic function, sexual desire, intercourse satisfaction, and overall satisfaction. It is useful to detect areas of difficulty and determine the degree of severity. The maximum score of the erectile function section is 30. Between 6 and 10 points is considered as serious dysfunction, moderate between 11 and 16, slight between 17 and 25, and finally normal erectile function if the patient get a score between 26 and 30. The total score is ranged between 7 and 70 points. The higher score reached, the better the sexuality of men is.

On female patients, FSFI test was used. [6] The FSFI (Appendix B) has an adequate sensitivity and specificity and has been translated and validated into Spanish. It is composed of 19 questions grouped into the following six domains: desire, arousal, lubrication, orgasm, satisfaction, and pain. Each question has 5 or 6 options, assigning a score ranging from 0 to 5. The value of each domain is multiplied by a factor determined by Rosen et al.[5] and the final result is the arithmetic sum of the different domains. The higher score reached, the better the sexuality of women is.


   Results Top


All patients in our series had at baseline, PASI, and BSA over 10, being then, candidates for biologic therapy for psoriasis. In all cases, the treatment used was naive after a clearance period of one month from cessation of systemic therapy with either methotrexate or cyclosporine.

The average age was 38.56±3.18 years and 34.47±5.43 years for male and female patients, respectively. The remaining demographics data from our series could be appreciated in [Table 1]. The mean PASI in males at the beginning of treatment was 12.45. Six months later, this mean was reduced to 1.8, reaching in all cases, the PASI 75 response. We found similar results on female patients with a PASI reduction from 15.25 to 1.4.
Table 1: Demographic date from male and female patients in our study

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Considering the women from our study, an improvement in FSFI by an average of 6.3 points is observed, with special modifications to the parameters of satisfaction and excitement [Table 2]. In male patients, the IIEF mean indicates a mild erectile dysfunction (22.5), which improved at 6 months of biologic therapy with an average increase of 9.5 points in the IIEF. All variations experimented for each domain are detailed in [Table 3].
Table 2: Domains of female sexual function and evolution

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Table 3: Domains of male sexual function and evolution

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   Discussion Top


We considered our series as a first step for a more detailed approach to the study of sexual function in patients with psoriasis. As we have previously stated, this is a pilot study. The number of patients has been small and we have included them consecutively if they met the selection criteria previously reported. However, despite the limitations that can be extracted, we believe that the results are relevant on focusing in the improvement of the sexual dimension of quality of life from our patients.

Sexual function is clearly impaired in patients with chronic diseases of all kinds, pulmonary, rheumatology, urology, etc. There are not many studies regarding the impact of psoriasis on sexual life΄s quality. [7],[8]

Gupta and Gupta [9] in 1997 was pioneer in the study of the sexual dimension on psoriatic patients. 40.8% of patients from his research have sexual dysfunction, although alcohol abuse and depression state could condition their sexual function. For this reason, we have excluded those patients with anxiolytic or antidepressant treatment. Türel Ermertcan et al.[10] in 2006 performed his study comparing a control group with two different groups of patients suffering from psoriasis (with or without depression). They concluded that sexual function for both men and women with psoriasis is decreased compared with the control group regardless of whether or not associated with their depressive status.

In our series, we have observed a clear improvement in FSFI and IIEF rates associated with a good response to treatment with biological therapy. These results reveal the impairment of the sexual dimension in the quality of life of patients with moderate to severe psoriasis, so we consider necessary to extend the sample and the assessment of the quality of life in a generic way besides using the questionnaires exposed to explore the sexual dimension.


   Appendix Top


Appendix A - International index of erectile function (IIEF) questionnaire

  1. Over the past 4 weeks, how often were you able to get an erection during sexual activity?
    • No sexual activity
    • Almost always or always
    • Most times (much more than half the time)
    • Sometimes (about half the time)
    • A few times (much less than half the time)
    • Almost never or never
  2. Over the past 4 weeks, when you had erections with sexual stimulation, how often were your erections hard enough for penetration?
    • No sexual stimulation
    • Almost always or always
    • Most times (much more than half the time)
    • Sometimes (about half the time)
    • A few times (much less than half the time)
    • Almost never or never
    • Questions 3, 4, and 5 will ask about erections you may have had during sexual intercourse.
  3. Over the past 4 weeks, when you attempted sexual intercourse, how often were you able to penetrate (enter) your partner?
    • Did not attempt intercourse
    • Almost always or always
    • Most times (much more than half the time)
    • Sometimes (about half the time)
    • A few times (much less than half the time)
    • Almost never or never
  4. Over the past 4 weeks, during sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner? • Did not attempt intercourse • Almost always or always
    • Most times (much more than half the time)
    • Sometimes (about half the time)
    • A few times (much less than half the time)
    • Almost never or never
  5. Over the past 4 weeks, during sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?
    • Did not attempt intercourse
    • Almost always or always
    • Most times (much more than half the time)
    • Sometimes (about half the time) 0 A few times (much less than half the time)
    • Almost never or never
  6. Over the past 4 weeks, how many times have you attempted sexual intercourse?
    • No attempts
    • 1-2 attempts
    • 3-4 attempts
    • 5-6 attempts
    • 7-10 attempts
    • 11 or more attempts
  7. Over the past 4 weeks, when you attempted sexual intercourse, how often was it satisfactory for you?
    • Did not attempt intercourse
    • Almost always or always
    • Most times (much more than half the time)
    • Sometimes (about half the time)
    • A few times (much less than half the time)
    • Almost never or never
  8. Over the past 4 weeks, how much have you enjoyed sexual intercourse?
    • No intercourse
    • Very highly enjoyable
    • Highly enjoyable
    • Fairly enjoyable
    • Not very enjoyable
    • Not enjoyable
  9. Over the past 4 weeks, when you had sexual stimulation or intercourse, how often did you ejaculate?
    • Did not attempt intercourse
    • Almost always or always
    • Most times (more than half the time)
    • Sometimes (about half the time)
    • A few times (much less than half the time)
    • Almost never or never
  10. Over the past 4 weeks, when you had sexual stimulation or intercourse, how often did you have the feeling of orgasm or climax (with or without ejaculation)?
    • No sexual stimulation or intercourse
    • Almost always or always
    • Most times (much more than half the time)
    • Sometimes (about half the time)
    • A few times (much less than half the time)
    • Almost never or never
    • Questions 11 and 12 ask about sexual desire. Let us define sexual desire as a feeling that may include wanting to have a sexual experience (for example, masturbation or intercourse), thinking about having sex or feeling frustrated due to a lack of sex.
  11. Over the past 4 weeks, how often have you felt sexual desire?
    • Almost always or always
    • Most times (much more than half the time)
    • Sometimes (about half the time)
    • A few times (much less than half the time)
    • Almost never or never
  12. Over the past 4 weeks, how would you rate your level of sexual desire?
    • Very high
    • High
    • Moderate
    • Low
    • Very low or none at all
  13. Over the past 4 weeks, how satisfied have you been with your overall sex life?
    • Very satisfied
    • Moderately satisfied
    • About equally satisfied and dissatisfied
    • Moderately dissatisfied
    • Very dissatisfied
  14. Over the past 4 weeks, how satisfied have you been with your sexual relationship with your partner?
    • Very satisfied
    • Moderately satisfied
    • About equally satisfied and dissatisfied
    • Moderately dissatisfied
    • Very dissatisfied
  15. Over the past 4 weeks, how do you rate your confidence that you can get and keep your erection?
    • Very high
    • High
    • Moderate
    • Low
    • Very low


Appendix B: Female sexual function index (FSFI) questionnaire

Sexual desire or interest is a feeling that includes wanting to have a sexual experience, feeling receptive to a partner's sexual initiation, and thinking or fantasizing about having sex.

  1. Over the past 4 weeks, how often did you feel sexual desire or interest?
    • Almost always or always
    • Most times (more than half the time)
    • Sometimes (about half the time)
    • A few times (less than half the time)
    • Almost never or never
  2. Over the past 4 weeks, how would you rate your level (degree) of sexual desire or interest?
    • Very high
    • High
    • Moderate
    • Low
    • Very low or none at all
    • Sexual arousal is a feeling that includes both physical and mental aspects of sexual excitement. It may include feelings of warmth or tingling in the genitals, lubrication (wetness), or muscle contractions.
  3. Over the past 4 weeks, how often did you feel sexually aroused ("turned on") during sexual activity or intercourse?
    • No sexual activity
    • Almost always or always
    • Most times (more than half the time)
    • Sometimes (about half the time)
    • A few times (less than half the time)
    • Almost never or never
  4. Over the past 4 weeks, how would you rate your level of sexual arousal (turn on) during sexual activity or intercourse?
    • No sexual activity
    • Very high
    • High
    • Moderate
    • Low
    • Very low or none at all
  5. Over the past 4 weeks, how confident were you about becoming sexually aroused during sexual activity or intercourse?
    • No sexual activity
    • Very high confidence
    • High confidence
    • Moderate confidence
    • Low confidence
    • Very low or no confidence
  6. Over the past 4 weeks, how often have you been satisfied with your arousal (excitement) during sexual activity or intercourse?
    • No sexual activity
    • Almost always or always
    • Most times (more than half the time)
    • Sometimes (about half the time)
    • A few times (less than half the time)
    • Almost never or never
  7. Over the past 4 weeks, how often did you become lubricated (wet) during sexual activity or intercourse?
    • No sexual activity
    • Almost always or always
    • Most times (more than half the time)
    • Sometimes (about half the time)
    • A few times (less than half the time)
    • Almost never or never
  8. Over the past 4 weeks, how difficult was it to become lubricated (wet) during sexual activity or intercourse?
    • No sexual activity
    • Extremely difficult or impossible
    • Very difficult
    • Difficult
    • Slightly difficult
    • Not difficult
  9. Over the past 4 weeks, how often did you maintain your lubrication (wetness) until completion of sexual activity or intercourse?
    • No sexual activity
    • Almost always or always
    • Most times (More than half the time)
    • Sometimes (about half the time)
    • A few times (less than half the time)
    • Almost never or never
  10. Over the past 4 weeks, how difficult was it to maintain your lubrication (wetness) until completion of sexual activity or intercourse?
    • No sexual activity
    • Extremely difficult or impossible
    • Very difficult
    • Difficult
    • Slightly difficult
    • Not difficult
  11. Over the past 4 weeks, when you had sexual stimulation or intercourse, how often did you reach orgasm (climax)?
    • No sexual activity
    • Almost always or always
    • Most times (more than half the time)
    • Sometimes (about half the time)
    • A few times (less than half the time)
    • Almost never or never
  12. Over the past 4 weeks, when you had sexual stimulation or intercourse, how difficult was it for you to reach orgasm (climax)?
    • No sexual activity
    • Extremely difficult or impossible
    • Very difficult
    • Difficult
    • Slightly difficult
    • Not difficult
  13. Over the past 4 weeks, how satisfied were you with your ability to reach orgasm (climax) during sexual activity or intercourse?
    • No sexual activity
    • Very satisfied
    • Moderately satisfied
    • About equally satisfied and dissatisfied
    • Moderately dissatisfied
    • Very dissatisfied
  14. Over the past 4 weeks, how satisfied have you been with the amount of emotional closeness during sexual activity between you and your partner?
    • No sexual activity
    • Very satisfied
    • Moderately satisfied
    • About equally satisfied and dissatisfied
    • Moderately dissatisfied
    • Very dissatisfied
  15. Over the past 4 weeks, how satisfied have you been with your sexual relationship with your partner?
    • Very satisfied
    • Moderately satisfied
    • About equally satisfied and dissatisfied
    • Moderately dissatisfied
    • Very dissatisfied
  16. Over the past 4 weeks, how satisfied have you been with your overall sexual life?
    • Very satisfied
    • Moderately satisfied
    • About equally satisfied and dissatisfied
    • Moderately dissatisfied
    • Very dissatisfied
  17. Over the past 4 weeks, how often did you experience discomfort or pain during vaginal penetration?
    • Did not attempt intercourse
    • Almost always or always
    • Most times (more than half the time)
    • Sometimes (about half the time)
    • A few times (less than half the time)
    • Almost never or never
  18. Over the past 4 weeks, how often did you experience discomfort or pain following vaginal penetration?
    • Did not attempt intercourse
    • Almost always or always
    • Most times (more than half the time)
    • Sometimes (about half the time)
    • A few times (less than half the time)
    • Almost never or never
  19. Over the past 4 weeks, how would you rate your level (degree) of discomfort or pain during or following vaginal penetration?
    • Did not attempt intercourse
    • Very high
    • High
    • Moderate
    • Low
    • Very low or none at all


 
   References Top

1.Mercan S, Altunay IK, Demir B, Akpinar A, Kayaoglu S. Sexual dysfunctions in patients with neurodermatitis and psoriasis. J Sex Marital Ther 2008;34:160-8.   Back to cited text no. 1
    
2.Sampogna F, Gisondi P, Tabolli S, Abeni D; IDI multipurpose psoriasis research on vital experiences investigators. Impairment of sexual life in patients with psoriasis. Dermatology 2007; 214:144-50.   Back to cited text no. 2
    
3.Rosen RC, Riley A, Wagner G, Osterloh IH, Kirkpatrick J, Mishra A. The international index of erectile function (IIEF): A multidimensional scale for assessment of erectile dysfunction. Urology 1997;49:822-30.  Back to cited text no. 3
    
4.Gutiérrez P, Hernández P, Sanz E, Cardeñosa O, Mas M. Further psychometric validation of the sexual life quality questionnaire for men with erectile dysfunction and their partners on a modified Spanish language version. J Sex Med 2009;6:2698-706.   Back to cited text no. 4
    
5.Rosen R, Brown C, Heiman J, Leiblum S, Meston C, Shabsigh R, et al. The Female Sexual Function Index (FSFI): A multidimensional self-report instrument for the assessment of female sexual function. J Sex Marital Ther 2000;26:191-208.  Back to cited text no. 5
    
6.Sánchez F, Pérez Conchillo M, Borrás Valls JJ, Gómez Llorens O, Aznar Vicente J, Caballero Martín de Las Mulas A. Design and validation of the questionnaire on Women's Sexual Function (WSF)] Aten Primaria 2004;34:286-92.  Back to cited text no. 6
    
7.Russo PA, Ilchef R, Cooper AJ. Psychiatric morbidity in psoriasis: A review. Australas J Dermatol 2004;45:155-9.  Back to cited text no. 7
    
8.Reynolds OD. Erectile dysfunction in etretinate treatment. Arch Dermatol 1991;127:425-6.   Back to cited text no. 8
    
9.Gupta MA, Gupta AK. Psoriasis and sex: a study of moderately to severely affected patients. Int J Dermatol 1997;36:259-62.  Back to cited text no. 9
    
10.Türel Ermertcan A, Temeltaº G, Deveci A, Dinç G, Güler HB, Oztürkcan S. Sexual dysfunction in patients with psoriasis. J Dermatol 2006;33:772-8.  Back to cited text no. 10
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]

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