Quality of life in mothers of children with psoriasis

Patients' and their mothers' quality of life is severely affected by childhood psoriasis. Almost all children have a chronic illness that lasts until adulthood, which puts them at risk for lifelong difficulties like stigma, psychiatric comorbidity, and suicide.

Taking care of kids with psoriasis can have an impact on their physical health, increase household expenses, and cause them emotional pain. The effect of childhood psoriasis on carers' quality of life is not well understood. 5 So, in an effort to clarify its function in the development of the condition and maybe aid in therapy, we set out to explore the impact of childhood psoriasis on the mothers' quality of life and evaluate its link with disease severity.

| PATIENTS AND ME THODS
This is a cross-sectional observational study that was carried out on 100 mothers of children who are below 18 years of age and presented with different clinical forms of psoriasis. The patients were recruited from the outpatient clinic during the period between December 2021 and August 2022. The mothers' quality of life was assessed using Family Dermatology Life Quality Index (FDLQI). the study was conducted after obtaining an oral informed consent from all participants.

| Inclusion criteria
Mothers of children with psoriasis below 18 years of age, cooperative and educated mothers who able to read and understand Arabic, were included in the study.

| Exclusion criteria
Mothers or children with mental illness, mothers or children with history of any systemic disorder, uneducated mothers, uncooperative mothers, mothers refused to participate or absent from the consultation, were excluded from the study.

| Children data
All children were subjected to complete history taking including: Personal history as name, age, sex and residence. Present history as onset, course, and duration of psoriasis. Past history of any chronic diseases, for example, DM, thyroid or other autoimmune diseases.
Family history of the same condition.
All children were subjected to, general examination for assessment of mental health, as well as, dermatological evaluation to determine site and extent of psoriasis by using Psoriasis Area Severity Index (PASI score).

| Mothers' data
All mothers were instructed to fill FDLQI questionnaire designed by Basra et al. FDLQI has been developed for the family members of patients with skin disorders, which asking their families or partners about the effect of patient's skin disorders on a number of different aspects of their QoL. 4 FDLQI is easy and can be simply handed to the patient who is asked to fill it without the need for more information. It is usually completed in short time.
The questionnaire contain ten items that covers family member's QoL over the last one month. Each question consisting of 4 alternative answers: "not at all," "a little," "a lot," or "very much" with scores of 0, 1, 2 and 3, respectively. The answer "not relevant," is scored as "0." The FDLQI is calculated by summing the score of each question, resulting in a minimum of 0 and maximum of 30. The higher the score, the greater the impairment of QoL and vice versa.

| Statistical methods
Statistical analysis and data processing were performed using sta-

| RE SULTS
Regarding clinic-demographic data of studied children, their ages ranged from 2-16 years with mean 9.12 ± 3.77 years. They are 59 boys and 41 girls. More than half of patients were rural residents.
Most of the studied mothers (94%) were educated. Duration of psoriasis ranged from 2 months to 8 years with mean 3.1 ± 1.99 years.
According to type of psoriasis, most of patients (76%) presented with psoriasis vulgaris, (12%) of patients presented with palmoplantar psoriasis, and solitary plaque psoriasis, scalp and flexural psoriasis and Pustular psoriasis presented in (4 %) of patients each. Family history of psoriasis was positive in (11%) of patients. PASI score ranged from 0.3 to 23 with mean 3.03 ± 4.89, as shown in (Table 1).
There was significant direct correlation between FDLQI of mother with age of patients and PASI score; however, there was no significant correlation between FDLQI of mother and duration of psoriasis, as shown in (Table 2).
There was significant relation between FDLQI of mother with type of psoriasis and family history of psoriasis; however, there was no significant relation between FDLQI of mother and gender of studied patients, as shown in (Table 3).

| DISCUSS ION
This study was conducted on 100 children presented with different types of psoriasis, according to type of psoriasis, most of patients (76%) presented with psoriasis vulgaris (plaque psoriasis).
In accordance with our results, Salman et al. conducted a crosssectional study on 58 patients with psoriasis, FDLQI was used in the study and they reported that the most common subtypes of psoriasis was plaque psoriasis, which found in 62.1% of the patients. 3  The previous findings may be due to the fact that the most frequently seen type of psoriasis is psoriasis vulgaris, which constitutes about 90% of cases as the TNFα-IL23-Th17 axis plays an important role in T-cell-mediated plaque psoriasis, which is found in majority of psoriatic patients; however, it is not found in different pathomechanisms associated with psoriasis subtypes. 7,8 In our study, family history of psoriasis was positive in (11%) of patients. This goes in line with Zychowska et al. who conducted a study on 96 children with psoriasis, and they found that psoriasis was positive in 9.23% in the caregivers. 9 On the other hand, Salman et al. found that family history psoriasis presented in (20.7%) of the patients. 3 A previous research has revealed a familial genetic predisposition of psoriasis, with more than 20% of patients having a positive family history. 10 Another study reported that 30 % of patients with psoriasis have affected first-degree relatives. 11 This difference between previous studies and ours may be due to different sample size as well as genetic and ethnic background of studied patients. 12,13 In accordance with our results, Zychowska et al. conducted two recent studies on the impact of childhood psoriasis on caregivers.
The first one was conducted on 45 children with psoriasis and their parents. Both parents of each child were asked to fill in the FDLQI questionnaire. In their study, the QoL of mothers was significantly more impaired than the QoL of fathers. The second one was conducted on 96 children with psoriasis. At the end of the study they found that childhood psoriasis exerts significant impact on caregivers' QoL. The mean FDLQI was 13.62 ± 6.15, which corresponds to "very large" impact on the family member's life. 9,14 The FDLQI instrument has also been used by Salman  TA B L E 2 Correlation between FDLQI of mother and clinicdemographic data of the studied children. TA B L E 3 Relation between FDLQI of mother and clinicdemographic data of the studied children.

Girls/boys
Boys   patients but also, partners' and families' lives. 16 In addition, a Swedish study showed emotional distress and financial burden on the families of pediatric patients with psoriasis. 17 Finally, a previous review in 2019 revealed that parents indicated their children's psoriasis affected their own QoL, causing depression, frustration, and stress. 18 The previous findings may be explained by the fact that, in our culture, mothers spent a lot of time with their children, take care of them during illness, are responsible for cooking, cleaning, washing and are considered to be more emotionally connected with them. In addition, dealing with other people's reactions due to the child's psoriasis was a great problem for mothers. Moreover, mothers usually hold themselves responsible for the condition of their child's skin. 14 In our study, we found significant direct correlation between This may be due to the visible nature of the skin lesion leading to the avoidance of outdoor activity. 19 These negative thoughts about their skin may impact the self-esteem of children and put them at a risk of psychiatric conditions. 20 In this study, we did not find any significant relation between FDLQI of mother and gender of studied children, which is in continuation with several previous studies. 3,21 On the other hand, some studies showed that caregivers of girls tended to have higher FDLQI scores than caregivers of boys. 9,22 The previous findings may be due to the cultural emphasis on appearance that highly affects women compared with men, with an associated increased impact in those affected by visible skin pathology. 9 Moreover, previous study reflected that the main risk for depression in patients with psoriasis were female gender, because of poor perception of their appearance, increased psychological distress, poor self-worth, and reduced emotional social support. 23 In our study, we found significant direct correlation between FDLQI of mothers and PASI score, as increase in children's PASI score was associated with poorer QoL of mothers. In accordance with our results, Bruins et al. conducted a prospective, cohort study on 319 children and adolescents with psoriasis, to identify the association between PASI and QOL, and they found a significant direct correlation between PASI and QOL scores in pediatric patients with psoriasis. 24

| RECOMMENDATIONS
We recommend a larger multicenter research that would take into account age, sex, geographical and cultural differences, in order to reliably assess the impact of childhood psoriasis families' QoL.

| CON CLUS ION
From our study we can conclude that, childhood psoriasis may have a negative affection on QoL of both affected children and their caregivers. FDLQI is a dermatology-specific instrument that can be used to measure the impact of psoriasis on family members and/ or caregivers, in case of pediatric patients. The impact of childhood psoriasis on mother may be affected by age of children, PASI score and type of psoriasis. Childhood psoriasis, may be a highly timeconsuming and financially burdensome issue for relatives, leading to substantial emotional distress. So, psychological support strategies must be offered to both the pediatric patients, and to the family members.

FU N D I N G I N FO R M ATI O N
No funding source.