Background: Psoriasis is a chronic immune-mediated inflammatory disease associated with significant physical, psychological, and social burden. The COVID-19 pandemic and lockdown measures created major challenges for patients with chronic diseases through healthcare disruption, limited medication accessibility, financial difficulties, and increased psychological stress, which may have negatively affected psoriasis severity and patient well-being.

Objective: to investigate the impact of the COVID-19 pandemic and lockdown on disease severity, mental health, quality of life, treatment accessibility, coping strategies, and financial burden among patients with psoriasis.

Methods: A multicenter cross-sectional observational study was conducted on 141 psoriasis patients attending the hospitals. Sociodemographic, clinical, psychological, and financial data were collected through patient interviews and medical records. Disease severity was assessed using Psoriasis Area and Severity Index (PASI), Body Surface Area (BSA), and Psoriasis Disability Index (PDI). Psychological assessment included Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI), and Perceived Stress Scale (PSS). Health-related quality of life was evaluated using the SF-36 questionnaire.

Results: The mean age of participants was 41.19 ± 13.68 years, and 55.3% were males. Psoriasis symptoms worsened moderately to severely in 64.5% of patients during lockdown. Significant increases were observed in PASI, BSA, and PDI scores after lockdown (p<0.05). Moderate anxiety was reported in 59.6% of patients, while 41.1% experienced high stress levels. Significant negative correlations were found between SF-36 scores and anxiety, depression, and stress scores (p<0.001). Difficulties obtaining medications and healthcare services were reported by 68.8% and 95.7% of patients, respectively. Logistic regression identified higher BMI, anxiety severity, financial burden, and lower quality of life scores as significant predictors of worsening psoriasis symptoms.

Conclusions: The COVID-19 pandemic had a substantial negative impact on psoriasis severity, mental health, healthcare accessibility, and quality of life. Multidisciplinary management, psychological support, and improved healthcare accessibility are essential to optimize psoriasis care during future public health crises.

Psoriasis is a chronic immune-mediated inflammatory skin disease that affects patients physically, psychologically, and socially, resulting in substantial impairment in health-related quality of life. The disease is characterized by a relapsing and remitting course and is frequently associated with several systemic co-morbidities including obesity, hypertension, diabetes mellitus, cardiovascular diseases, and psoriatic arthritis. In addition to its physical manifestations, psoriasis has a considerable psychological burden, as patients commonly experience anxiety, depression, stress, social stigma, and impaired emotional well-being. Therefore, successful psoriasis management requires continuous medical care, treatment adherence, psychosocial support, and regular follow-up. 

The emergence of the Coronavirus Disease 2019 (COVID-19) pandemic created unprecedented challenges for healthcare systems worldwide, particularly for patients with chronic diseases requiring long-term management. Lockdown measures, social isolation, fear of infection, transportation restrictions, financial instability, healthcare disruption, and limited access to medications negatively affected patients with psoriasis. Moreover, concerns regarding the safety of immunosuppressive therapies during the pandemic contributed to treatment interruption and reduced healthcare utilization, which may have resulted in worsening disease severity and impaired quality of life. 

Although several studies evaluated the impact of COVID-19 on psoriasis patients, most focused on limited aspects such as treatment adherence, biologic therapy safety, or psychological distress separately. There remains limited comprehensive data evaluating the combined clinical, psychological, social, and financial impact of the pandemic on psoriasis patients, especially in developing countries and Middle Eastern populations. Furthermore, few studies simultaneously assessed disease severity, mental health, quality of life, coping strategies, healthcare accessibility, and financial burden within the same patient population. This represents an important literature gap requiring further investigation. 

The novelty of our study lies in providing a comprehensive multidimensional assessment of psoriasis patients during the COVID-19 pandemic by evaluating physical health, psychological burden, quality of life, coping strategies, healthcare accessibility, medication adherence, and financial impact together in one Egyptian cohort. In addition, the study compared several clinical and laboratory parameters before and after lockdown, allowing objective assessment of the pandemic’s effect on psoriasis outcomes. 

Therefore, our study was performed to investigate the overall impact of the COVID-19 pandemic and lockdown on patients with psoriasis. The study specifically aimed to assess the effects of the pandemic on disease severity, psychological and emotional health, health-related quality of life, coping mechanisms, healthcare accessibility, treatment adherence, and financial burden among studied psoriasis patients.

Patients And Methods

This multicenter cross-sectional observational study was conducted on 141 patients clinically diagnosed with psoriasis attending the Dermatology outpatient clinics of El-Aml Specialized Hospital, Al-Haud Al-Marsoud Hospital, and Zagazig General Hospital, Egypt, during the period from March 2020 to May 2022 to investigate the impact of the COVID-19 pandemic and lockdown on patients with psoriasis. Eligible patients were identified through the hospital data registry and had attended the unit during the period from March 2020 to May 2022. All procedures were carried out in accordance with ethical standards for human research. 

Inclusion Criteria

Participants were selected according to predefined inclusion criteria. Eligible participants were adult patients aged 18 years or older with a confirmed clinical diagnosis of psoriasis who had regularly attended the hospitals during the year preceding the COVID-19 lockdown in Egypt. Patients were required to have complete medical records and valid contact information to allow communication during the study period. In addition, only patients who were willing to participate in the psychosocial evaluation and provide informed consent were included in the study. 

Exclusion Criteria

Patients were excluded if their medical records contained invalid or outdated contact information or lacked sufficient baseline clinical data. Patients who refused participation in the psychosocial assessment were also excluded. Additional exclusion criteria included the presence of other dermatological diseases that could affect physical or emotional health and interfere with study assessment, intellectual disability or major cognitive impairment preventing questionnaire completion, and patients with major psychiatric disorders. 

1. Baseline Assessment and Data Collection

All included patients underwent detailed assessment through review of medical records and direct patient interviews. Sociodemographic data including age, gender, residence, occupation, marital status, and annual income were collected. Detailed clinical history was obtained with special emphasis on psoriasis type, disease course, duration, associated co-morbidities, treatment history, and accessibility to healthcare services and medications during lockdown.

Clinical evaluation included assessment of psoriasis severity using Psoriasis Area and Severity Index (PASI), Body Surface Area (BSA), and Psoriasis Disability Index (PDI). Anthropometric measurements including weight, body mass index (BMI), and waist circumference were also recorded before and after lockdown. Laboratory investigations including complete blood count (CBC), liver function tests, kidney function tests, fasting blood glucose, HbA1c, and lipid profile were reviewed and compared before and after lockdown. 

2. Psychological and Quality of Life Assessment

Psychological and emotional assessment was performed using validated questionnaires. Anxiety levels were assessed using the Beck Anxiety Inventory (BAI), while depressive symptoms were evaluated using the Beck Depression Inventory (BDI). Stress levels were assessed using the Perceived Stress Scale (PSS). Health-related quality of life was evaluated using the Short Form-36 (SF-36) questionnaire, which assessed physical, emotional, social, and mental health domains. In addition, coping strategies adopted by psoriasis patients during the pandemic were evaluated using coping assessment questionnaires covering both adaptive and maladaptive coping mechanisms. 

3. Assessment of Healthcare Accessibility and Financial Impact

Patients were interviewed regarding accessibility to healthcare services and medication availability during the COVID-19 lockdown. Data regarding difficulties obtaining medications from KAPU, inability to attend follow-up visits, transportation restrictions, fear of infection, financial difficulties, and healthcare service disruption were documented. The financial impact of the pandemic on work status, income, savings, financial obligations, and ability to obtain healthcare services was also assessed. 

Sample Size

The study included 141 psoriasis patients. The sample size was considered adequate to evaluate the clinical, psychological, social, and financial impact of the COVID-19 pandemic on psoriasis patients and to allow appropriate statistical analysis of the studied variables. 

Ethical Considerations

All participants were informed about the objectives and procedures of the study before enrollment. Written informed consent was obtained from all patients or their legal guardians prior to participation. Confidentiality and privacy of patient data were maintained throughout the study period. 

Data were analyzed using the Statistical Package for Social Science (SPSS) software version 24. Qualitative variables were presented as frequencies and percentages, while quantitative variables were expressed as mean ± standard deviation (SD) or median and interquartile range (IQR) when appropriate. Paired sample t-test was used to compare quantitative variables before and after lockdown, while Chi-square test was applied for comparison of categorical variables. Correlation analysis was performed using Pearson correlation coefficient. Logistic regression analysis was conducted to identify independent predictors of worsening psoriasis symptoms. Odds ratios (OR) and 95% confidence intervals (CI) were calculated. A p-value less than 0.05 was considered statistically significant.

The results of the present study are demonstrated in the following tables.

Table (1) demonstrated that the mean age of the studied participants was 41.19 ± 13.68 years. Males represented 55.3% of the studied population, while females represented 44.7%. Rural residents constituted 51.8% of participants, whereas 48.2% were urban residents. Most participants were working (68.1%) and married (80.1%). The median annual income was 24,000 Egyptian pounds. 

Table 1: Baseline data of the studied participants; (N= 141)

$the annual income was calculated for (96) participants only.

Data is presented as N (%) for qualitative data. 

Mean ±SD for normally distributed quantitative data. 

Median and interquartile range (IQR) for non-normally distributed quantitative data

Table (2) showed that classic psoriasis was the most prevalent clinical type among studied patients (84.4%), followed by scalp psoriasis (61.7%), nail psoriasis (22%), and flexural psoriasis (19.1%). Palmoplantar psoriasis was present in 10.6% of participants, while guttate, erythrodermic, pustular psoriasis, and chronic palmoplantar pustulosis were less frequent. 

Table 2: Clinical types of psoriasis among studied participants; (N=141)

N.B: Patient could have more than one psoriasis type at the same time.

Data is presented as N (%) for qualitative data. 

Table (3) demonstrated that more than half of the studied psoriasis patients (56%) had a progressive disease course, while 42.6% experienced remission and exacerbation episodes. Only 1.4% showed a regressive disease course. 

Table 3: Disease coarse among studied participants; (N= 141)

Covid-19 Pandemic Lockdown Burden on Physical Health of Patients with Psoriasis

Table (4) demonstrated worsening of psoriasis symptoms during the lockdown period. Moderate worsening was reported in 31.9% of patients, while 32.6% reported severe worsening. Only 18.4% reported no change in symptoms. 

Table 4: Change in Psoriasis Symptoms among studied participants.

Table (5) showed that itching symptoms increased during lockdown among most studied patients. Severe increase in itching was reported by 40.4% of participants, while 27% experienced moderate increase. Only 15.6% reported no change in itching severity. 

Table 5: Change in Itching Symptom among studied participants

Table (6) demonstrated that 36.9% of psoriasis patients had associated co-morbidities before lockdown, whereas 63.1% had no associated co-morbid conditions. 

Table 6: Associated Co-morbidities among studied participants before lockdown; (N= 141)

Table (7) demonstrated that hypertension was the most prevalent co-morbidity among studied patients (12.1%), followed by diabetes mellitus (10.6%) and hepatitis C virus infection (7.1%). Other co-morbidities were less frequent. 

Table 7: Types of Associated Co-morbidities

N.B: Patient could have more than one co-morbidity at the same time.

Data is presented as N (%) for qualitative data. 

Table (8) showed that 18.4% of participants developed new associated co-morbidities after lockdown, while the majority of patients (81.6%) did not report newly developed co-morbid conditions. 

Table 8: New Associated Co-morbidities among studied participants after lockdown; (N= 141)

Table (9) demonstrated no statistically significant differences in anthropometric measures before and after lockdown. Weight, BMI, and waist circumference showed minimal changes with p-values greater than 0.05. 

Table 9: Comparison of anthropometric measures among Studied Psoriasis Patients before and after Lockdown

Data is presented as Mean ±SD. 

Statistical analysis carried out by: Paired Sample-t test analysis.

*p-value ≤0.05 is considered statistically significant.

Table (10) demonstrated significant increases in overall laboratory abnormalities after lockdown compared with before lockdown (46.8% vs. 31.2%, p=0.010). CBC abnormalities also significantly increased after lockdown (14.9% vs. 6.4%, p=0.016). Other laboratory parameters showed no statistically significant differences. 

Table 10: Comparison of laboratory assessment among studied psoriasis patients before and after Lockdown

Data is presented as N (%) for qualitative data. 

Statistical analysis carried out by: Chi-Square test analysis.

*p-value ≤0.05 is considered statistically significant.

Table (11) demonstrated significant worsening in psoriasis severity scores after lockdown. BSA significantly increased from 12.42 ± 14.59 to 17.17 ± 22.40 (p=0.014), PDI increased from 12.42 ± 9.94 to 13.63 ± 9.71 (p=0.040), and PASI increased from 6.30 ± 5.76 to 7.42 ± 6.69 (p=0.037).

Table 11: Comparison of clinical assessment scores of psoriasis disease among Studied Psoriasis Patients before and after Lockdown

 BSA: Body Surface Area; PDI: Psoriasis disability index; PASI: Psoriasis Area and Severity Index 

Data is presented as Mean ±SD. 

Statistical analysis carried out by: Paired Sample-t test analysis.

*p-value ≤0.05 is considered statistically significant.

Table (12) demonstrated significant worsening in psoriatic arthritis scores after lockdown. The percentage of patients with normal findings decreased from 70.2?fore lockdown to 39.7?ter lockdown (p=0.001). 

Table 12: Psoriatic Arthritis Score Comparison among Studied Psoriasis Patients before and after Lockdown

Data is presented as N (%) for qualitative data. 

Statistical analysis carried out by: Chi-Square test analysis.

*p-value ≤0.05 is considered statistically significant.

Assessment of Emotional and Mental Health among Studied Psoriasis Patients

Table (13) showed that moderate anxiety was present in 59.6% of studied patients, while potentially concerning anxiety levels were reported in 12.1%. Regarding depression, 21.3% of patients had borderline clinical depression, 21.3% had moderate depression, and 17% had severe to extreme depression. 

Table 13: Prevalence of Depression and Anxiety according to Beck depression inventory and Beck anxiety inventory scores among studied population

(BDI): Beck depression inventory, (BAI): Beck anxiety inventory

Table (14) demonstrated that 49.6% of participants experienced moderate stress levels, while 41.1% reported high stress levels according to the Perceived Stress Scale. 

Table 14: Prevalence of Stress according to Perceived stress scale scores among studied population

(PSS): Perceived stress scale

Table (15) demonstrated impaired health-related quality of life among studied psoriasis patients. The highest mean score was observed in physical functioning (75.85 ± 22.43), while the lowest score was recorded in role emotional (34.74 ± 39.61). The mean total SF-36 score was 51.18 ± 18.60. 

Table 15: Health related quality of life assessment among studied population

Table (16) demonstrated statistically significant negative correlations between total SF-36 scores and psychological measures. SF-36 negatively correlated with BDI scores (r=-0.319, p<0.001), BAI scores (r=-0.368, p<0.001), and PSS scores (r=-0.479, p<0.001). 

Table 16: Correlation between Quality of Life as Assessed by Sf-36 with Emotional and Mental Health among Studied Psoriasis Patients; (N= 141)

*. Correlation is significant at the 0.05 level (2-tailed).

**. Correlation is significant at the 0.01 level (2-tailed).

(BDI): Beck depression inventory, (BAI): Beck anxiety inventory, (PSS): Perceived stress scale

Table (17) demonstrated that religion was the most commonly used coping strategy among psoriasis patients (6.98 ± 1.50), followed by planning, active coping, instrumental support, emotional support, and acceptance. Substance use was the least utilized coping strategy. 

Table 17: Ways of coping in patients with psoriasis; (N= 141)

Table (18) demonstrated significant positive correlations between perceived stress and behavioral disengagement, self-blame, and self-distraction. Significant negative correlations were observed between stress and venting, positive reframing, planning, humor, and acceptance. 

Table 18: Correlation between PSS and Ways of coping in patients with psoriasis; (N= 141)

*. Correlation is significant at the 0.05 level (2-tailed).

**. Correlation is significant at the 0.01 level (2-tailed).

(PSS): Perceived stress scale

Accessibility to Medical Prescriptions, Accessibility to Health Care Services, And Financial Affection among Studied Psoriasis Patients

Table (19) demonstrated that 61.7% of patients usually received treatment from KAPU before lockdown. Difficulties obtaining medications during lockdown were reported by 56.7% of patients, while 68.8% experienced problems purchasing medications mainly due to financial difficulties, inability to reach healthcare, and medication unavailability. 

Table 19: Medication Adherence among studies psoriasis patients; (N= 141)

Table (20) demonstrated that 95.7% of studied patients experienced problems with follow-up at KAPU during lockdown. Fear of the pandemic was the most commonly reported cause (66.7%), followed by transportation restrictions (50.4%) and financial difficulties (42.6%). 

Table 20: Problem with follow-up at KAPU among studies psoriasis patients; (N= 141)

*N. B: Patient could have more than one problem with follow-up at the same time.

Table (21) demonstrated marked financial impact of the COVID-19 pandemic on psoriasis patients. Work was affected in 77.1% of employed participants, income was affected in 79.1%, savings were affected in 77%, and financial obligations were affected in 75% of patients. 

Table 21: Financial affection among studied psoriasis patients; (N= 141)

*N. B: for income affection, the total number of participants who answered the question was 134, and 7 missing data. Savings affection, the total number of participants who answered the question was 135, and 6 missing data. Financial obligations affection the total number of participants who answered the question was 136, and 5 missing data.

Table (22) demonstrated that BMI was significantly higher among patients with moderate-to-severe worsening of psoriasis symptoms compared with patients with no or little worsening (31.87 ± 7.99 vs. 27.26 ± 7.13, p<0.001). Other variables showed no statistically significant differences. 

Change in Psoriasis Symptoms among Studied Participants

The following tables compare the relation of different studied factors with the change in Psoriasis Symptoms among studied participants:

Table 22: Basic Characteristics among studied population according to changes in psoriasis symptoms

Table (23) demonstrated significantly higher BDI, BAI, and PSS scores among patients with moderate-to-severe worsening of psoriasis symptoms compared with those with no or little worsening (p<0.05). 

Table 23: Beck depression inventory and Beck anxiety inventory scores among studied population according to changes in psoriasis symptoms

(BDI): Beck depression inventory, (BAI): Beck anxiety inventory.

Table (24) demonstrated significantly lower physical functioning, social functioning, and total SF-36 scores among patients with moderate-to-severe worsening of psoriasis symptoms compared with patients with no or little worsening. 

Table 24: Health related quality of life assessment among studied population according to changes in psoriasis symptoms

Table (25) demonstrated no statistically significant differences in coping strategies between patients with no-to-little worsening and those with moderate-to-severe worsening of psoriasis symptoms (p>0.05). 

Table 25: Ways of coping in patients with psoriasis according to changes in psoriasis symptoms

Table (26) demonstrated that BMI, anxiety severity, income affection, financial obligations affection, and total SF-36 score were significant independent predictors of worsening psoriasis symptoms according to logistic regression analysis. The overall regression model was statistically significant (p=0.013) with an overall prediction accuracy of 71.9%.

Table 26: Logistic Regression analysis for patient-reported outcomes of psoriasis with other studied variables

Variable(s) entered on analysis: BMI, BDI Score, BAI Score, PSS Score, receive drug from KAPU before lockdown, difficult to get drug from KAPU during lock down, work affection, income affection, savings affection, financial obligations affection, Total SF36 score.

Psoriasis is a chronic immune-mediated inflammatory disease that affects patients physically, psychologically, and socially, leading to significant impairment in quality of life. The disease is commonly associated with several co-morbidities and requires long-term treatment, regular follow-up, and continuous psychosocial support. Due to its chronic relapsing nature and visible skin manifestations, psoriasis is frequently linked to anxiety, depression, stress, and social stigma. 

The COVID-19 pandemic created major challenges for patients with chronic diseases, including psoriasis. Lockdown measures, fear of infection, healthcare disruption, transportation difficulties, financial burden, and limited access to medications negatively affected disease management and patient well-being. These factors may have contributed to worsening psoriasis symptoms, psychological distress, impaired quality of life, and treatment interruption during the pandemic period. 

Despite increasing interest in the impact of COVID-19 on chronic diseases, there remains limited comprehensive data evaluating the combined clinical, psychological, social, and financial burden of the pandemic on psoriasis patients, particularly in Egyptian populations. Consequently, our study aimed to investigate the impact of the COVID-19 pandemic and lockdown on patients with psoriasis, with special emphasis on physical health, psychological status, quality of life, coping strategies, healthcare accessibility, medication adherence, and financial burden.

Our study included 141 psoriatic patients with a mean age of 41.19 ± 13.68 years, ranging from 18 to 70 years. Males represented 55.3% of the studied population, while females accounted for 44.7%. Additionally, 51.8% of participants were rural residents, 68.1% were employed, and 80.1% were married. The median annual income was 24,000 Egyptian pounds (IQR = 18,000). These findings are generally consistent with the study conducted by Oguz Topal et al. (2022), who evaluated 342 psoriasis patients during the COVID-19 pandemic and reported a mean age of 45.9 ± 14.2 years with a slight male predominance (53.2% males and 46.8?males). Similarly, Kartal et al. (2022) included 1827 psoriasis patients receiving immunosuppressive therapy and also demonstrated male predominance among studied patients. 

In contrast, Mahil et al. (2021) reported different demographic characteristics in their multinational cross-sectional study involving 4043 psoriasis patients from 86 countries, where females represented 66.5% of participants. This difference may be attributed to the online self-reported nature of their survey and broader international representation. Meanwhile, Beytout et al. (2021) studied pediatric psoriasis patients and reported a lower mean age of 11.4 ± 3.5 years because their study specifically focused on children and adolescents during lockdown. The demographic similarities between our study and the Turkish studies suggest that psoriasis predominantly affected economically active middle-aged adults during the pandemic, increasing the psychosocial and financial burden on patients.

Regarding Clinical Characteristics of Psoriasis, our study demonstrated that classic plaque psoriasis was the predominant clinical type, affecting 84.4% of patients. Scalp psoriasis was reported in 61.7%, nail psoriasis in 22%, flexural psoriasis in 19.1%, and palmoplantar psoriasis in 10.6% of participants. Moreover, 56% of patients exhibited a progressive disease course, while 42.6% experienced remission and exacerbation episodes. 

These findings closely resemble those reported by Oguz Topal et al. (2022), who found plaque psoriasis in 95.3% of studied patients, confirming that plaque psoriasis remained the dominant subtype during the pandemic period. Likewise, Beytout et al. (2021) observed that 71.7% of pediatric psoriasis patients had active psoriatic lesions during lockdown, emphasizing persistent disease activity despite age differences. 

Additionally, Kartal et al. (2022) reported persistent disease activity among patients receiving immunosuppressive therapy and evaluated disease progression according to patient-reported outcomes and PASI scores. The consistency among studies indicates that psoriasis activity remained inadequately controlled during the pandemic, likely due to healthcare disruption, treatment interruption, and psychological stress.

Regarding Effect of Lockdown on Psoriasis Symptoms, our study demonstrated substantial worsening of psoriasis symptoms during the COVID-19 lockdown. Approximately one-third of participants (32.6%) reported that their psoriasis became “a lot worse,” while another 31.9% experienced “moderately worse” symptoms. Only 18.4% reported no change in symptoms. Furthermore, itching severity increased markedly, with 40.4% reporting a major increase in itching symptoms and 27% reporting moderate worsening. 

Comparable findings were observed by Beytout et al. (2021), who reported worsening psoriasis in 47.3% of children during lockdown. The authors identified stress (48.8%) and treatment discontinuation (18.6%) as the major triggers for flare-ups. Similarly, Mahil et al. (2021) found that 42.7% of psoriasis patients experienced worsening disease during the pandemic. Moreover, Kartal et al. (2022) reported disease worsening in 24.2% of psoriasis patients and demonstrated that treatment dose reduction increased worsening risk by 3.26 times, while treatment discontinuation increased worsening risk by 8.71 times. 

The similarity between our findings and previous studies strongly supports the hypothesis that lockdown-related stress, social isolation, treatment interruption, and reduced access to healthcare contributed significantly to psoriasis exacerbation during the pandemic.

Regarding Co-Morbidities Among Studied Patients, our study found that 36.9% of psoriasis patients had associated co-morbidities before lockdown, while 18.4?veloped new co-morbidities after lockdown. Hypertension was the most common co-morbidity (12.1%), followed by diabetes mellitus (10.6%) and hepatitis C virus infection (7.1%). 

These findings are supported by Gisondi et al. (2020), who evaluated 5206 psoriasis patients receiving biologic therapy in Northern Italy and found high frequencies of hypertension (30.8%), obesity (25%), cardiovascular disease (12%), diabetes mellitus (12.2%), and psoriatic arthritis (27.6%). Similarly, Mahil et al. (2021) reported that 39.7% of psoriasis patients had at least one co-morbidity during the pandemic. 

Furthermore, Beytout et al. (2021) documented co-morbidities in 17.4% of pediatric patients, mainly asthma and metabolic disorders, though at lower rates compared with adult studies. The increased prevalence of metabolic and cardiovascular diseases among psoriasis patients emphasizes their heightened vulnerability during COVID-19.

Regarding Anthropometric and Laboratory Changes, our study demonstrated no statistically significant changes in weight, BMI, or waist circumference before and after lockdown. Mean BMI increased minimally from 28.69 ± 7.08 kg/m² to 28.83 ± 6.85 kg/m² (p=0.861). However, patients with moderate-to-severe worsening of psoriasis had significantly higher BMI values (31.87 ± 7.99 kg/m²) compared with patients with mild or no worsening (27.26 ± 7.13 kg/m², p<0.001). 

This finding agrees with Mahil et al. (2021), who identified obesity as a significant independent predictor of worsening psoriasis during the pandemic (OR=1.22). In addition, our study revealed a significant increase in abnormal laboratory findings after lockdown, particularly CBC abnormalities, which increased from 6.4?fore lockdown to 14.9?ter lockdown (p=0.016). 

These laboratory deteriorations may reflect increased systemic inflammation, chronic stress, treatment interruption, or delayed medical follow-up during the pandemic.

Regarding Clinical Severity Scores, our study revealed significant worsening in psoriasis severity indices following lockdown. PASI scores significantly increased from 6.30 ± 5.76 before lockdown to 7.42 ± 6.69 after lockdown (p=0.037). Similarly, BSA significantly increased from 12.42 ± 14.59 to 17.17 ± 22.40 (p=0.014), while PDI scores increased from 12.42 ± 9.94 to 13.63 ± 9.71 (p=0.040). 

Similarly, Oguz Topal et al. (2022) demonstrated that higher PASI scores negatively influenced treatment adherence and were associated with increased disease burden. Likewise, Kartal et al. (2022) confirmed that treatment discontinuation and dose reduction were strongly associated with worsening psoriasis severity. 

The observed increase in PASI, BSA, and disability scores across studies highlights the substantial impact of healthcare interruption during lockdown on psoriasis control.

Regarding Psoriatic Arthritis Findings, our study demonstrated significant worsening in psoriatic arthritis manifestations after lockdown. Normal findings decreased from 70.2?fore lockdown to 39.7?ter lockdown (p=0.001), indicating increased joint involvement and disease activity. 

Similarly, Gisondi et al. (2020) reported psoriatic arthritis in 27.6% of biologically treated psoriasis patients. Additionally, Oguz Topal et al. (2022) evaluated psoriatic arthritis among psoriasis patients receiving systemic therapies and highlighted its negative impact on treatment adherence and quality of life. 

These findings suggest that delayed healthcare access and treatment interruption during lockdown may have contributed to worsening musculoskeletal symptoms among psoriasis patients.

Regarding Psychological and Emotional Impact, our study demonstrated a considerable psychological burden among psoriasis patients during the pandemic. Moderate anxiety affected 59.6% of participants, while moderate, severe, and extreme depression affected 21.3%, 8.5%, and 8.5% respectively. Additionally, 41.1% of patients experienced high perceived stress levels. 

These findings are strongly supported by Mahil et al. (2021), who demonstrated that anxiety and depression were significantly associated with worsening psoriasis. Patients with worsening psoriasis showed positive mental health screening in 50.2% of cases compared with 28.8% among those without worsening disease. Furthermore, Beytout et al. (2021) identified stress as the most common trigger for psoriasis exacerbation during lockdown. 

Similarly, Oguz Topal et al. (2022) used the Hospital Anxiety and Depression Scale (HADS) and demonstrated that psychological distress negatively affected treatment adherence during the pandemic. These findings confirm the close bidirectional relationship between psychological stress and psoriasis severity.

Regarding Health-Related Quality of Life, our study revealed substantial impairment in health-related quality of life among psoriasis patients. The mean total SF-36 score was 51.18 ± 18.60, while role emotional scored lowest (34.74 ± 39.61), indicating major emotional impairment. Moreover, SF-36 scores negatively correlated with anxiety (r=-0.368), depression (r=-0.319), and stress scores (r=-0.479), all with p<0.001. 

Comparable findings were reported by Oguz Topal et al. (2022), who demonstrated impaired Dermatology Life Quality Index (DLQI) scores among psoriasis patients during the pandemic. Likewise, Mahil et al. (2021) emphasized the indirect morbidity of the pandemic, particularly worsening mental health and impaired quality of life among psoriasis patients. 

These studies collectively demonstrate that COVID-19 negatively affected both physical and emotional dimensions of quality of life in psoriasis patients.

Regarding Coping Strategies, our study showed that religion (6.98 ± 1.50), planning (5.41 ± 1.72), acceptance (5.07 ± 2.10), and active coping (5.26 ± 1.89) were the most frequently utilized coping strategies among psoriasis patients. Furthermore, stress positively correlated with maladaptive coping mechanisms such as behavioral disengagement (r=0.212, p=0.012) and self-blame (r=0.376, p<0.001), while acceptance and positive reframing negatively correlated with stress. 

Although the compared studies did not specifically assess coping strategies, Mahil et al. (2021) emphasized the importance of psychological support and holistic healthcare models during the pandemic. Our findings add important psychosocial dimensions regarding behavioral adaptation during health crises.

Regarding Accessibility to Healthcare and Medication, our study demonstrated major disruptions in healthcare access during lockdown. Difficulties obtaining medications from KAPU were reported by 56.7% of patients, while 68.8% experienced problems buying medications mainly due to financial difficulties (55.3%), healthcare inaccessibility (34%), and medication unavailability (25.5%). 

Similarly, Oguz Topal et al. (2022) found that inability to attend hospital visits (19.2%), concern about COVID-19 infection (16.3%), physician-directed discontinuation (13.7%), and inability to access medications (7.3%) were major causes of treatment interruption. Likewise, Kartal et al. (2022) reported that inability to attend follow-up visits was the leading reason for treatment withdrawal during the pandemic. 

Importantly, Beytout et al. (2021) highlighted the major role of teleconsultation, as 71.1% of consultations during lockdown were performed remotely. These findings emphasize the necessity of implementing telemedicine and remote healthcare systems during future pandemics.

Regarding Financial Impact of the Pandemic, our study revealed significant financial burdens among psoriasis patients. Work was negatively affected in 77.1% of employed patients, income reduction occurred in 79.1%, savings were affected in 77%, and financial obligations worsened in 75% of participants. Furthermore, 66% reported that financial difficulties negatively affected their ability to obtain medications and healthcare services. 

Similarly, Mahil et al. (2021) found that shielding measures, employment disruptions, and psychological stress contributed significantly to worsening psoriasis during the pandemic. Additionally, Kartal et al. (2022) highlighted reduced healthcare access and treatment interruption caused by pandemic-related restrictions. 

These findings demonstrate the profound socioeconomic consequences of the COVID-19 pandemic on psoriasis patients and their treatment continuity.

Regarding Factors Associated with Worsening Psoriasis Symptoms, our study demonstrated that higher BMI, anxiety, depression, stress, and impaired quality of life were significantly associated with worsening psoriasis symptoms. Patients with moderate-to-severe worsening had significantly higher BMI (31.87 ± 7.99 vs. 27.26 ± 7.13, p<0.001), BDI scores (23.40 ± 12.24 vs. 17.89 ± 10.79, p=0.005), BAI scores (27.97 ± 7.49 vs. 23.69 ± 7.49, p=0.001), and PSS scores (25.88 ± 6.31 vs. 23.18 ± 7.95, p=0.027). 

These findings are consistent with Mahil et al. (2021), who identified obesity, anxiety, depression, female gender, and treatment non-adherence as major predictors of worsening psoriasis. Similarly, Kartal et al. (2022) demonstrated that treatment withdrawal significantly increased disease worsening risk. 

Regarding Logistic Regression Analysis, our logistic regression analysis identified BMI, anxiety severity, financial affection, and lower SF-36 scores as significant independent predictors of worsening psoriasis symptoms. BMI significantly increased worsening risk (OR=1.119, p=0.003), while anxiety severity measured by BAI also predicted worsening disease (p=0.014). 

These findings strongly agree with Mahil et al. (2021), who found that positive anxiety or depression screening doubled the odds of worsening psoriasis (OR=2.01), while treatment non-adherence increased worsening risk nearly threefold (OR=2.90). Additionally, Kartal et al. (2022) demonstrated that treatment withdrawal and dose reduction were strong predictors of psoriasis aggravation during the pandemic.

Clinical Implications

Our study demonstrated that the COVID-19 pandemic had a major negative impact on psoriasis patients at clinical, psychological, and social levels. Significant worsening was observed in psoriasis severity, itching symptoms, psoriatic arthritis manifestations, anxiety, depression, stress, and quality of life. These findings emphasize that psoriasis management should not focus only on skin manifestations but should include psychological assessment, emotional support, and social care. The study also highlighted the importance of maintaining continuous access to healthcare services and medications during health crises. Telemedicine and remote follow-up can play an important role in preventing treatment interruption and disease aggravation during future pandemics or lockdowns.

Strength Points

One of the main strengths of our study is the comprehensive evaluation of psoriasis patients during the COVID-19 pandemic. The study assessed multiple dimensions including clinical severity, laboratory findings, psychological health, quality of life, coping strategies, healthcare accessibility, and financial burden. Another strength is the use of validated assessment tools such as PASI, PDI, SF-36, Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI), and Perceived Stress Scale (PSS), which increased the reliability and accuracy of the findings. In addition, comparing patients before and after lockdown provided objective evidence regarding the impact of the pandemic on psoriasis outcomes.

Despite its strengths, our study had some limitations. The study was conducted at a single tertiary center with a relatively limited sample size, which may reduce the generalizability of the findings to other populations. The cross-sectional observational design also limits the ability to establish causal relationships between the pandemic and worsening psoriasis outcomes. Some data were based on patient self-reporting, which may have introduced recall bias, especially regarding symptom worsening, psychological status, and financial impact during lockdown. Furthermore, the absence of a healthy control group limited comparisons between psoriasis patients and the general population regarding psychological and social burden during the pandemic.

Our study concluded that the COVID-19 pandemic significantly affected patients with psoriasis physically, psychologically, socially, and financially. There was marked worsening in psoriasis severity scores, itching symptoms, psoriatic arthritis manifestations, and quality of life after lockdown. Anxiety, depression, and stress were highly prevalent among patients and were significantly associated with worsening psoriasis symptoms. Difficulties in accessing healthcare services, obtaining medications, and financial hardship further contributed to disease aggravation and impaired patient well-being. Logistic regression analysis identified higher BMI, anxiety severity, financial burden, and lower quality of life scores as important predictors of worsening psoriasis symptoms during the pandemic.

Based on our findings, multidisciplinary management approaches should be implemented for psoriasis patients, especially during public health emergencies. Routine screening for anxiety, depression, and stress should be integrated into dermatology practice with appropriate psychological support when needed. Telemedicine services and online consultations should be strengthened to maintain continuity of care during lockdowns or healthcare disruptions. Healthcare providers should educate patients regarding the importance of treatment adherence and reassure them about the safety of continuing prescribed therapies unless contraindicated. In addition, health authorities should improve medication availability and provide financial support for patients with chronic diseases during crises.

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Author Contributions

Ahmed Adel Ali Ali contributed to study supervision, conception and design, data collection, statistical analysis, interpretation of data, and manuscript drafting. Fatema Saber participated in clinical assessment, data acquisition, literature review, and manuscript revision. Marwa Mahdy contributed to methodology development, interpretation of results, supervision of the study process, and critical revision of the manuscript. All authors read and approved the final version of the manuscript. 

The authors declared that there were no conflicts of interest regarding the publication of this study. 

Confidentiality of Data

All collected data were kept confidential and used only for scientific research purposes. Participants’ identities were anonymized using coded numbers instead of personal identifiers. Access to study data was restricted to the research team only. 

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The study was self-funded by the authors.