According to the World Health Organization (WHO), psoriasis (Ps) is a chronic, non-communicable, painful, disfiguring, and disabling disease, with no cure and a significant negative impact on the patient's quality of life (QoL).1

Despite therapeutic advances, some patients do not achieve complete clearance of skin signs or continue to have other issues that negatively affect their QoL.2 This, along with differing expectations and priorities between dermatologists and patients in disease management,3 requires changes to adjust treatment on an individual basis, objectively measuring results4,5 to achieve a holistic approach to disease management.6

Disease severity measures can be objective (Psoriasis Activity Skin Index [PASI], Body Surface Area [BSA], or percentage of skin affected; Physician Global Assessment [PGA]), or subjective, evaluated by the patient (Dermatology Life Quality Index [DLQI]). However, each of these indices has intrinsic limitations, as previously mentioned.7

In 2017, the Psoriasis Working Group (PWG) of the Spanish Academy of Dermatology and Venereology embarked on a project to create a measure that jointly assessed the impact of the disease between patient and dermatologist, which gave birth to the Minimal Disease Activity in Psoriasis (MDA).7 MDA includes the dermatologist's evaluation of the BSA, presence or absence of special localization, and the exclusion of arthritis. The patient scores the DLQI and quantifies the intensity of itching (0-10), erythema (0-10), scaling (0-10), and visibility (0-10). MDA is met in the absence of active arthritis plus 3 of the following items: itching ≤ 1/10; scaling ≤ 2/10; redness ≤ 2/10; visibility ≤ 2/10; BSA ≤ 2; DLQI ≤ 2, and no lesions in special locations.

The objective of our study was to describe the MDA situation in the routine clinical practice in Spain.

We conducted a national, observational, cross-sectional, and multicenter study. Each region provided information from 10 dermatologists through one coordinator. Participant dermatologists consecutively collected data from 5 patients with plaque Ps and no active arthritis. Informed consent, epidemiological and clinical data (sex, age, therapeutic status, and drug used; presence or absence of special location; and confirmation of the absence of active arthritis), PASI, BSA, DLQI, as well as patient-reported intensity of itching, erythema, scaling, and visibility were collected.

Data were entered by each regional coordinator into a web platform specifically designed by the research unit of AEDV, responsible for the analysis.

A descriptive analysis was conducted where continuous variables were expressed as mean and standard deviation (SD), median, first and third quartile, and maximum and minimum. Differences were evaluated using the Student's t-test or the Mann-Whitney U test. Qualitative variables were expressed as absolute and relative frequencies, and differences were evaluated using the chi-square test. A smoothed line chart of the probability of not meeting MDA criteria based on PASI was created to determine an optimal cut-off point through logistic regression. Finally, multivariable logistic regression adjusted by region was used to determine the association between meeting MDA criteria and different epidemiological and clinical characteristics.

The study was approved by Hospital Universitario de Gran Canaria Dr. Negrín Ethics Committee of (2022-299-1). All patients gave their consent to participate in the study.

A total of 18 coordinators and 180 dermatologists from across Spain participated in the study collecting data from 830 patients with vulgar Ps and without active arthritis. Data were obtained from 17 autonomous communities—except for Ceuta and Melilla—and 44 of the 50 provinces, with differences across regions: Catalonia 124 patients, maximum; Balearic Islands, 4 patients, minimum). Of these, 493 were men (59.5%) with a mean age of 51.4 years (SD, 14.2 years) (Table 1).

The mean disease severity values as measured by dermatologist and patient were: BSA, 4.7; PASI, 3.5; DLQI, 3.5; itching, 2.9; scaling, 3.2; erythema, 3.1; visibility, 3.3 (Table 2).

A total of 61.7% had no lesions in special locations, 47.8% had itching ≤ 1/10; 53.9%, scaling ≤ 2/10; 54.2%, redness ≤ 2/10; 55.1%, visibility ≤ 2/10; 55.4%, BSA ≤ 2; and 59%, DLQI ≤ 2 (Table 3).

More than half of the patients (491; 59.2%) did not meet MDA criteria, and we found significant differences across regions (highest frequency in Asturias: 98%; lowest in Catalonia: 37.1%) (p <0.001) (Graph 1).

Figure 1.

Adherence to MDA by regions and gender.

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MDA compliance showed significant differences by sex and age. Men had a higher percentage of MDA compliance (222 patients, 45.0% vs 117 women, 34.8%) (p <0.003), as did older patients (mean age, 52.9 years; SD, 14.3) vs younger patients (50.4 years; SD, 14) (p <0.013). Additionally, differences in compliance by sex were seen across regions (Graph 1).

Additionally, differences were reported in MDA compliance based on treatment (p <0.001). Biological therapy was associated with higher MDA compliance vs non-biological therapy (59.4% vs 23.3%). Although no differences were seen between different biological therapies (p=0.108), significant differences were found vs non-biological therapies (p <0.001) (Table 4).

Subjective symptoms reported by patients—itching, scaling, erythema, visibility—were the main reason for not meeting MDA, mainly itching> 1 (72.5%) (Supplementary data).

A total of 23% of patients with PASI: 0 (45, 22.3%) did not meet MDA criteria (Table 5). For every unit increase in PASI, the risk of not meeting MDA criteria almost doubled (regardless of treatment); OR, 1.84 (95%CI, 1.61-2.10). In this risk, a change in trend is observed from PASI scores of 5 where increments are not as pronounced (Graph 2).

Figure 2.

Probability of not meeting MDA criteria based on PASI score.

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Using a multivariable logistic model, we found that the probability of meeting/not meeting MDA criteria involved the simultaneous use of biological drugs, PASI, age, sex, and geographic region. None of these factors alone—not even the use of biological drugs—explained the differences found (Table 6).

The data can be accessed through the viewer: https://aedv.es/grupos-de-trabajo/psoriasis/visualizador-de-casos-de-proyecto-ame/

Being a national study as it is, patient sample is expected to be heterogeneous due to geographic diversity, which can influence the different sensitivities in appreciating the subjective parameters measured by the patient, different perceptions of symptoms based on cultural differences, differences in dermatologist experience (specialized vs general clinic, urban vs rural), different access to more effective drugs,29 etc.

Although patients were not randomized, they were recruited during routine clinical practice over a short period of time (1-2 days), which may have introduced a participation and selection bias by recruiting the most active participants or those who happened to attend the clinic on those days.

After applying the MDA nationwide, it seems obvious that adherence is relatively low, with significant differences being reported by sex, age, region, type of therapy, and symptoms reported by patients. However, none of these factors alone explained the differences found, and the use of biological drugs alone could not account for the existing differences.

Evaluating MDA vs PASI provides a better approach to patients by allowing them to participate in measuring the severity of their disease, which could lead to a qualitative improvement in the management of these patients.

The use of MDA in routine clinical practice is easy and convenient, and it can improve the quality of psoriatic patient management by including parameters not considered in other widely used severity scales. Therefore, we encourage dermatologists treating psoriatic patients to use MDA as a measure of disease severity and a therapeutic goal.

G. Carretero Hernández: study design, data mining, result interpretation, national coordination of the study, lead author of the manuscript.

Ara Martín, Mariano: data mining, result interpretation, regional coordination of the study in Aragón, lead author of the manuscript.

Armesto Alonso, Susana: data mining, result interpretation, regional coordination of the study in Cantabria, lead author of the manuscript.

Belinchón Romero, Isabel: data mining, result interpretation, regional coordination of the study in the Valencian Community, lead author of the manuscript.

Eiris Salvado, Noemi: data mining, result interpretation, regional coordination of the study in Andalusia, lead author of the manuscript.

Ferrán Farrés, Marta: data mining, result interpretation, regional coordination of the study in Catalonia, lead author of the manuscript.

Galache Osuna, Cristina: data mining, result interpretation, regional coordination of the study in Asturias, lead author of the manuscript.

García Bustínduy, Marta: data mining, result interpretation, regional coordination of the study in the Canary Islands, lead author of the manuscript.

García Latasa de Araníbar, Javier: data mining, result interpretation, regional coordination of the study in Aragón, lead author of the manuscript.

Juliá Manresa, Marc: data mining, result interpretation, regional coordination of the study in the Basque Country, lead author of the manuscript.

Llamas Velasco, Mar: data mining, result interpretation, regional coordination of the study in Madrid, lead author of the manuscript.

López Ferrer, Anna: data mining, result interpretation, regional coordination of the study in Catalonia, lead author of the manuscript.

Roncero Riesco, Mónica: data mining, result interpretation, regional coordination of the study in Castile and León, lead author of the manuscript.

Ruiz Genao, Diana: data mining, result interpretation, regional coordination of the study in Madrid, lead author of the manuscript.

Ruiz-Villaverde, Ricardo: data mining, result interpretation, regional coordination of the study in Andalusia, lead author of the manuscript.

Salgado Boquete, Laura: data mining, result interpretation, regional coordination of the study in Galicia, lead author of the manuscript.

Soria Martínez, Caridad: data mining, result interpretation, regional coordination of the study in Murcia, lead author of the manuscript.

Vilarrasa Rull, Eva: data mining, result interpretation, regional coordination of the study in Cataluña and the Balearic Islands, lead author of the manuscript.

Descalzo, M.A.: data analysis, result interpretation, manuscript preparation.

None declared.