Paraclinical Characteristics of Patients Before Treatment

According to Do Quang Trong's study, among 152 patients studied, 19.74% had a family history of psoriasis [129]. Swanbeck et al.'s study showed that if no parents had psoriasis in the family, or only one parent had the disease or both parents had psoriasis, the risk of the child having psoriasis was 0.04; 0.28; 0.65, respectively. If there was an affected child in the family, the corresponding risks were 0.24; 0.51 and 0.83 [130]. According to Dang Van Em et al.'s study on psoriasis patients at the 108 Central Military Hospital, this rate was 10.46% [131]. Meanwhile, Tran Van Tien's study (2004) at the Central Dermatology Hospital showed that the rate of patients with a family history was 7.46% [15]. According to chart 3.4, 19.64% of patients have a family history of psoriasis. Our research results are higher than those of domestic and foreign research results, possibly because we collected information on family history of psoriasis in 3 generations. However, we cannot deny that psoriasis is a familial disease, the risk of psoriasis in people with psoriasis in the family is higher than in people without a family history. Further research on genes and genetics in psoriasis patients in Vietnam is needed to clarify this issue.

History of treatment prior to study entry

According to the results in Table 3.2, among topical medications, corticosteroids were used most (80.36%), followed by keratolytics and finally calcipotriol, accounting for 58.93% and 44.64%, respectively. Among systemic medications, methotrexate was used most, accounting for 28.57%. Notably, 3 patients (5.36%) used systemic corticosteroids. Among these 3 patients, one patient used oral tablets containing corticosteroids of unknown origin purchased on his own, and two patients used injectable corticosteroids (K-cort) at a private clinic. During clinical practice, we also found that many cases of patients with psoriasis were prescribed oral or injectable corticosteroids.

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For the treatment of psoriasis by private medical facilities, initially the patient's symptoms were noted to improve, but then the lesions often flared up more severely or changed from common psoriasis to other types of psoriasis. A patient in our study had a flare-up of pustular psoriasis all over the body after high-dose K-cort injections (4 vials/day) continuously for 5 days. Using systemic corticosteroids to treat common psoriasis is not recommended because of the risk of side effects of the drug when used long-term and the risk of progression from common to severe forms such as erythroderma or pustular psoriasis. According to Pham Thi Thao's study on 60 patients with severe psoriasis, 13.3% of patients had flare-ups after using systemic corticosteroids, especially in the group of patients with pustular psoriasis all over the body at 23.3% [132]. In addition, in the study, there was a high percentage of patients with a history of using traditional medicine to treat the disease, accounting for 30.36%. We need to advise patients to be cautious in using traditional medicine, especially traditional medicine of unknown origin. Because, according to Pham Thi Thao's research, 25% of patients had a flare-up after using traditional medicine, similarly according to Tran Van Tien's research, it was 17.91% [15], [132].

4.1.3. Disease triggering factors

Many studies have shown that physical labor and psychological stress are factors that stimulate the disease to worsen. In our study, it was also shown that 32.14% of patients had stress as a factor that triggered the disease. The results of the impact of psychological factors on the onset of the disease in our study were lower than those of Le Anh Tuan and Phan Huy Thuc, where stress accounted for 40.90% and 42.39%, respectively [126] [128]. This can be explained by the fact that in our study, only mental factors were considered, and all other issues were not evaluated, so the rate was lower. However, in general, it shows that mental factors and stress are one of the causes of the disease. Because the manifestations on the skin make patients feel inferior and self-conscious about the disease, and at the same time, they are afraid to communicate, making them susceptible to stress and the disease worsening. The spiral

pathology between psychological problems, stress and the severity of the disease. Therefore, medical staff need to combine treatment with psychological counseling.

Alcohol is also a factor related to the onset of psoriasis. According to table 3.3, 17.86% of patients have a factor that triggers the disease. This result is similar to Caroline Svanstrom's study of 95 psoriasis patients, which found that 17-30% of patients were affected by alcohol [133].

In our study, we evaluated the factors of drugs, infections and smoking as the factors that trigger psoriasis with the rates of 10.71%, 5.36% and 3.57%, respectively. Further evaluation is needed to conclude how these factors affect psoriasis.

4.1.4. Clinical characteristics of the study group

In our study, the subjects selected were patients with moderate and severe psoriasis, in which according to table 3.4, assessing the severity of the disease through the PASI index, the moderate group accounted for 87.50%, the severe group accounted for 12.50%. Regarding the accompanying nail lesions in our study, it was quite high, accounting for 69.64%. Our results are similar to the research results of domestic authors such as Tran Van Tien 70.9% [15], Pham Thi Thao 81.7% [132], and some foreign authors such as Bardazzi et al. found that nail manifestations in psoriasis patients manifested in the skin were 50-79% and up to 80% of patients with psoriatic arthritis [134]. Authors Muneer and Masood found nail manifestations in patients with psoriasis vulgaris and psoriatic arthritis at rates of 10% to 55% and 80% to 90%, respectively [135]. The mucosal manifestations in our study group according to table 3.7 were 3.57%.

According to Figure 3.5, the most common accompanying functional symptom of patients in the study group was itching, accounting for 73.21%. This result is similar to many authors such as Szepietowski and Reich, who assessed that itching affects 60-90% of patients with psoriasis [136]. Author Hawro et al. found that 80% of psoriasis patients had itching [137]. In addition, according to Figure 3.5, in

In our study, burning sensation was only present in 1 patient (1.79%) and no patient had skin pain.

DLQI is the most common measure used to assess health-related quality of life in psoriasis patients. It is one of the criteria for defining moderate to severe psoriasis and is included in treatment guidelines. The subjects participating in our study were moderate and severe patients, the patient quality of life assessment (DLQI) scores according to table 3.9 were mainly in the range of 6-20 points. Psoriasis greatly affects the patient's daily life. This corresponds to the goal of selecting participants in the study. In addition to the PASI index, BSA also needs to rely on DLQI to assess the severity of psoriasis to make appropriate treatment choices for patients.

4.1.5. Paraclinical characteristics of patients before treatment

We evaluated the blood count indexes before treatment to assess the condition and monitor the patients after treatment. The results in Table 3.7 show that the average indexes of red blood cells, white blood cells and platelets of the subjects participating in the study before treatment were within normal limits. Regarding blood biochemistry, the indexes in the metabolic syndrome we will mention below. According to Table 3.8, in terms of liver and kidney function through the average values of AST, ALT, bilirubin TP, TT and urea, creatinine were all within normal limits.

4.1.6. Characteristics related to metabolic syndrome

Chronic plaque psoriasis is an immune-mediated inflammatory skin disease associated with clinical features of metabolic syndrome including abdominal obesity, hypertension, dyslipidemia, type II diabetes, insulin resistance, and non-alcoholic fatty liver disease. In particular, the prevalence of metabolic syndrome in psoriasis patients ranges from 20% to 50%, with the risk being at least twice that of those without psoriasis [30]. In a previous study, we evaluated metabolic syndrome in 130 patients

In a study of pustular psoriasis conducted at the Central Dermatology Hospital in 2015, 40 patients had metabolic syndrome, accounting for 30.80% [31]. According to Table 3.9, in the study group, 8.93% of patients had hypertension, 32.14% of patients had increased fasting glucose, increased triglycerides, and cholesterol, respectively, 51.79% and 14.29%. In addition, in the patient group participating in our study, 29.41% of female patients and 12.82% of male patients had increased waist circumference. According to the study of Gisondi et al. [30], psoriasis and metabolic syndrome share many risk factors.

The association between obesity and psoriasis has been reported for many years, in the study of Paroutoglou et al. showed that obesity is associated with a higher incidence and severity of psoriasis, which is associated with a poor response to TNF-α biologics. Dietary modifications and exercise can improve pre-existing psoriasis and prevent the appearance of new psoriasis 7 . In our study, according to the table

3.10 Overweight patients accounted for 33.93%, and grade I obesity accounted for 14.29%. This result shows that there needs to be comprehensive coordination for each patient, from treatment to diet and exercise advice, especially for overweight and obese patients.

4.2. Treatment results of moderate and severe psoriasis vulgaris with narrow band ultraviolet (UVB 311nm) irradiation

4.2.1. Clinical treatment results

4.2.1.1. Treatment results according to PASI 75 index and quality of life index

According to the results in Table 3.11, the total number of patients achieving PASI 75 was 43, accounting for 76.79% of the total 56 patients who received the full treatment regimen (maximum 36 irradiations or until reaching PASI 75). Of the remaining 13 patients who did not achieve PASI 75, 7 patients achieved a reduction in PASI index from 50 - 75%, accounting for 12.5%, and 6 patients had poor response (did not achieve PASI 50), accounting for 10.71%.

This result is higher than the results of some studies by other authors. The double-blind study of Sami Yones et al. on 93 patients with moderate-severe plaque psoriasis treated with PUVA and narrow-band UVB, in which the author used the NB-UVB regimen twice a week in 47 patients. The result showed that the rate of lesion clearance was 65% in the NB-UVB treatment group [118]. It is possible that in this study, the author used the afternoon regimen twice a week, less than ours which was 3 times a week, besides, the author took the treatment result as the lesion clearance, higher than our study which took the result as only reaching PASI 75. Our results are also lower than the rate of lesion clearance in the PUVA-treated patients in this study with 84% of patients achieving treatment results out of a total of 46 patients treated with PUVA. This rate was significantly higher (p = 0.02) than in the NB-UVB group, thereby the author concluded that PUVA twice a week was more effective than NB-UVB twice a week.

Similar to the study by author Sami Yones, our results are also higher than the results in the study by PMGordon et al. in 1997 [139]. Gordon conducted a study on 100 patients with plaque psoriasis who were randomly divided into 2 groups: 51 patients in the NB-UVB group treated twice a week, 49 patients in the PUVA group treated twice a week. The results in the group of patients treated with NB-UVB showed a lesion clearance rate of 63%, so this rate was lower than the rate of achieving PASI 75 in our study. At the same time, this result was also significantly lower (p = 0.02) than the group of patients treated with PUVA with a lesion clearance rate of 84%.

Another study in 2004 by Tahir et al., conducted on 40 patients with moderate-severe plaque psoriasis, of which 20 patients received PUVA treatment 3 times/week and 20 patients received NBUVB treatment 3 times/week. This treatment regimen was similar to our study. The results showed that the rate of lesion clearance in the PUVA group was 85% compared to 60% in the NB-UVB group with p = 0.038. This result was also lower than the rate of achieving PASI 75 in the study.

ours. The authors also concluded that PUVA 3 times/week was more effective than NBUVB 3 times/week [119].

However, our treatment results were lower than those of T. Markham et al. on 29 patients treated with narrowband UVB 3 times/week, showing that 82.7% of patients achieved clear lesions [117]. This rate was similar to that of the PUVA treatment group at 84%. The difference between the two groups was not statistically significant. Here, the author took the treatment efficacy as the threshold for achieving clear lesions. However, the efficacy rate was still higher than that of our study. It can be explained that in this study, the author also used the same 3 times/week irradiation regimen as us, but used a starting dose of 70% MED and increased the dose by 20% each time, higher than our study with a starting dose of 50% MED and increased the dose by 10% each time.

Our results are similar to the study of Hoang Van Tam et al. in 2015, which was conducted at the same facility as our study. In which 30 patients were also treated with NBUVB 3 times/week with a lesion clearance rate of 76.67% [122]. However, in Hoang Van Tam's study, the author used the initial dose based on skin type, with an average starting dose of 500mJ/cm 2 , higher than our study.

Therefore, the incidence of side effects such as redness, itching, pigmentation disorders, etc. is higher. We found that NB-UVB treatment with a dose determined by the minimum dose of skin redness is effective, equivalent to fewer side effects than determining the dose by skin type.

As discussed above, when compared with PUVA, several studies have shown that NB-UVB treatment results are equivalent to PUVA while causing fewer adverse effects. A systematic review by Chen et al. in 2013 on a total of 662 psoriasis patients showed that the proportion of patients achieving PASI 75 in patients treated with NB-UVB and oral PUVA was virtually the same. The cumulative dose and relapse rates were also not statistically different between the two treatments. However,

However, patients treated with PUVA had a greater improvement in quality of life, as well as fewer treatment sessions achieving clear lesions than with NB-UVB, while patients treated with oral PUVA experienced a significant side effect of nausea [116].

In addition to the PASI75 index, which is the treatment objective that we studied, we also evaluated the treatment results according to the DLQI quality of life index before and after treatment at the end of the study, based on the 2011 European consensus treatment target [125] when the patient achieved DLQI ≤ 5. The results in Table 3.12 show that after treatment, the percentage of patients achieving DLQI ≤ 5 was 35.71%. This rate is significantly lower than the percentage of patients achieving PASI 75, which was 76.79%. This is because: first, the treatment goal of this study is for patients to achieve PASI 75, not the treatment goal for patients to have a DLQI ≤ 5. Therefore, when a patient achieves PASI 75, there may still be lesions in exposed skin areas such as the face, neck and hands. In addition, although PASI 75 has been achieved, the skin lesions have been clinically reduced by 75%, most of the lesions have cleared of scales, the degree of skin thickness and redness has been significantly reduced, but the hyperpigmentation lesions due to the side effects of ultraviolet radiation are still present... so the assessment at this time will still affect the patient's quality of life, especially in terms of daily social interaction. Second, the assessment of quality of life scores depends a lot on the patient's subjectivity and the patient's living environment. Most of the patients who achieved PASI 75 after treatment but did not achieve a DLQI score below 5 were patients who worked in occupations such as business, trading... having to meet and communicate with many people, so the disease greatly affected their lives, or for women, the need for aesthetics was higher, they paid more attention to their appearance than men, so when the disease had reduced but there were still traces of damage on the skin, they were not really satisfied with the quality of life. We believe that after treatment, when the skin damage had clearly improved, the disease still affected the patient's quality of life, not many patients really achieved a

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