Indonesian Journal of Rheumatology Vol 13 Issue 3 2023

Indonesian Journal of
Rheumatology
Journal Homepage: https://journalrheumatology.or.id/index.php/IJR

Correlation between Uric Acid Levels and the Severity of Psoriasis Vulgaris
Patients
Pristia Widya Monica1*, Nurrachmat Mulianto1
1 Department of Dermatology and Venereology, Faculty of Medicine, Universitas Sebelas Maret/Dr. Moewardi General Hospital,
Surakarta, Indonesia

ARTICLE INFO ABSTRACT

Keywords: Introduction: Psoriasis vulgaris (PV) is a recurrent chronic inflammatory
PASI score skin disease characterized by erythematous, scaly, well-defined plaques with
Psoriasis vulgaris the greatest predilection, generally in the areas of the elbows, knees, scalp,
and lower back. The psoriasis area and severity index (PASI) is one of the
Uric acid most widely used evaluation tools to determine the development of psoriasis
vulgaris in a patient. Hyperuricemia is the dominant risk factor for PV when
*Corresponding author: compared to other known risk factors, such as obesity or metabolic
Pristia Widya Monica syndrome. This study aimed to determine whether there is a relationship
between serum uric acid levels and the severity of PV based on the PASI
score. Methods: Cross-sectional study with one-time sampling conducted
E-mail address: from December 2021 to February 2022 in psoriasis vulgaris patients who
came to the Dermatology and Venereology clinic at Dr. Moewardi General
pristiawm@gmail.com Hospital, Surakarta, Indonesia. All data were statistically analyzed using
SPSS 26. Variables, including age, gender, disease duration, body mass
index, and uric acid levels, were subjected to univariate analysis. Bivariate
All authors have reviewed and approved the
analysis was then followed by a parametric test. The p-value <0.05 was
final version of the manuscript.
considered significant. Results: There were 36 patients during the study
period. The average uric acid level was 6.0135, with an average PASI score
https://doi.org/10.37275/IJR.v13i3.248 of 10.6388. The relationship between uric acid levels and the severity of
psoriasis vulgaris was found to be significant, with a value of p = 0.025.
Conclusion: There is a significant relationship between uric acid levels and
the severity of psoriasis vulgaris, where the higher the uric acid level, the
more severe the severity of psoriasis vulgaris.

1. Introduction PV in the dermatology and venereology polyclinic at

Psoriasis vulgaris (PV) is a chronic inflammatory Sanglah General Hospital for the period 2017 to 2018
disease brokered immunologically and is was 142 cases with 90 male patients (63.4%) and 52
characterized by skin inflammation, epidermal female patients (36.6%).6,7 The etiology of PV is a
hyperplasia, increased risk of arthritis, and complex disease with extrinsic and intrinsic causes.
increased cardiovascular morbidity. The course of Minor local trauma, drugs, HIV infection, and
this disease is a psychosocial challenge because it streptococcal pharyngitis are some causes of PV.
can lead to decreased quality of life and increased Temperature and natural sunlight exposure were
psychological stress in patients.1,2 The global mentioned as additional external factors that have a
prevalence of PV in children ranges from 2.1% in clinically significant effect on disease activity.8
Italy, while the prevalence in adults ranges from 0.4% Pathogenesis PV is characterized by persistent
in Asian countries to 8.5% in Norway.3,4,5 Dewi et al. inflammation leading to uncontrolled proliferation of
in 2018 in Denpasar informed that the incidence of keratinocytes and dysfunctional differentiation. This

752
pathogenesis is largely related to interactive
responses between infiltrating white blood cells,
dendritic cells, pro-inflammatory cytokines,
chemokines, and chemical mediators produced in
the skin. The clinical manifestations of PV are well-
defined erythematous plaques covered with silvery
scales. The lesions may progress over
consolidating and extending to the trunk and
limbs.9,10 Silvery scales are described as flat or mica.
Removal of scales can cause an Auspitz sign, which
is a bleeding spot at the base of the lesion.11,12
The psoriasis area and severity index (PASI) is one
of the most widely used evaluation tools to determine
the development of PV disease in a patient. A
researcher must assess and quantify
components of PASI, including engagement body
surface area (BSA), including face/scalp, trunk,
lower and upper extremities, as well as erythema,
induration, and scaling. The final PASI score (from 0
to 72) assesses the overall severity and extent of
Increased serum uric acid is thought to be related
to keratinocyte hyperproliferation and increased
epidermal cell turnover in PV patients. Serum uric
acid mediates the inflammatory pathway through the
secretion of chemokines proinflammatory. Increased
production of keratinocyte cells causes an increase
in purine metabolism, which also increases serum
uric acid levels in PV patients. Hyperuricemia is the
dominant complication in PV when compared to
other known complications such as obesity or
metabolic syndrome.14,15 This research is expected to
be useful for increasing knowledge about the
relationship between serum uric acid levels and the
severity of PV. This study aimed to determine the
relationship between serum uric acid levels and the
severity of PV based on the PASI score in patients at
the dermatology and venereology polyclinic, Dr.
Moewardi General Hospital, Surakarta.
2. Methods
This research is an observational analytic
research method cross-sectional conducted at the
dermatology and venereology polyclinic,
Moewardi General Hospital, Surakarta, from
December 2021 to February 2022. PV patients who
come to the polyclinic are involved as research
patient candidates using purposive sampling. The
study was conducted on 36 patients as a whole after
adjusting for inclusion and exclusion criteria. The
time, inclusion criteria in this study were all patients
diagnosed with PV and aged 16-70 years. Exclusion
criteria in this study were patients with a history of
diabetes mellitus, hypertension, heart disease, liver
disease, and thyroid disease, patients with a body
mass index > 30 kg/m2, patients with a history of
smoking and alcohol consumption, patients with a
history of diabetes mellitus. In the family, patients
several with a history of consumption of drugs that lower
serum uric acid levels, such as xanthine oxidase
inhibitors, uricosurics, urate oxidase enzymes, and
drugs that interfere with metabolisms such as
biguanides, sulfonylureas, beta blockers,
PV.13 hydrochlorothiazide diuretics, cyclosporine,
retinoids, corticosteroids and hormonal
contraceptives, and patients who refused to be study
patients.
History, physical examination, and laboratory
examinations are carried out by medical personnel.
Information collected based on the patient's medical
history and physical examination included a history
of diabetes mellitus, hypertension, heart disease,
liver disease, thyroid disease, drug consumption,
body mass index, family history of hyperuricemia,
dyslipidemia, smoking and alcohol consumption. The
severity of PV is measured using a PASI score with ≤
5 classified as mild PV, a PASI score with 6 – 10 is
classified as moderate PV and a PASI score ≥ 11 is
classified as severe PV. Uric acid levels are measured
using a blood sample after the patient fasts for 8-12
hours. The data obtained were then analyzed using
SPSS version 26 (IBM Corp., Chicago, USA) with a
significance limit of p <0.05. Variables, including age,
sex, disease duration, body mass index, and uric acid
levels, were subjected to univariate analysis.
Bivariate analysis was then followed by a parametric
Dr. test. Independent t test and non-parametric test are
753
performed if the data is normally distributed and the subjects (22%). A total of 14 subjects (39%) had PV
Mann-Whitney test is performed if the data is not for 0 – 8 years, while 12 subjects (12%) had PV for ≥
normally distributed. 9 years (Table 1).
The mean age of the study subjects was 48.81 ±
3. Results
12.028 years, with a mean duration of PV disease of
Subjects in this study totaled 36 PV patients
8.02 ± 7.569 years. The subjects studied had an
consisting of 23 male patients (64%) and 12 female
average PASI score of 10.6388 ± 8.10412 and uric
patients (36%). The most age was found in the age
acid levels of 6.075 ± 2.07246 (Table 2). Based on the
range of 46-70 years, as many as 21 subjects (58%).
PASI score, the characteristics of the research
Mild psoriasis vulgaris with PASI score ≤ 5 was found
subjects obtained a p-value> 0.05, which means that
in 14 subjects (39%), while moderate PV was found
the data is homogeneously distributed (Table 3).
in 8 subjects (22%), and severe PV was found in 8

Table 1. General characteristics of research subjects.

Characteristics Total (n = 36) Percentage (%)
Age
18 - 45 years 15 42%
46 - 70 years 21 58%
Gender
Male 23 64%
Female 13 36%
PV duration
0 - 8 years 24 67%
≥ 9 years 12 33%
PASI score
Mild (≤ 5) 14 39%
Moderate (6 - 10) 8 22%
Severe (≥ 11) 14 39%
Uric acid levels
Normal (≤ 6,1) 21 58%
High (≥ 6.2) 15 42%
Note: n = number of subjects, PASI =psoriasis area severity index.

Table 2. Descriptive characteristics of research subjects based on PASI scores.

Average
Characteristics Standard deviation
Statistics Standard error
Age 48,81 2,01 12,03
PV duration 8,02 1,26 7,57
PASI score 10,64 1,35 8,10
Uric acid levels 60,75 3,45 20,72
Note: PASI =psoriasis area severity index.

754
 Table 3. Characteristics of research subjects based on mild, moderate, and severe PASI scores.
Number (n) based on the
Number of PASI score
Variable r value P- value
subjects (n) Mild Moderate Severe
(PASI ≤ 5) (PASI 6 - 10) (PASI ≥ 11)
Age
18 - 45 years 15 7 2 6
0,00 0,91
46 - 70 years 21 7 6 8
Gender
Male 23 8 7 8
0,02 0,91
Female 13 6 1 6
PV duration
0 - 8 years 24 10 5 9
0,32 0,02
≥ 9 years 12 4 3 5
Uric acid levels
Normal (≤ 6,1) 21 14 7 7
0,27 0,05
High (≥ 6.2) 15 6 9 9
Note: PASI =psoriasis area severity index, r = correlation coefficient, P = asymptotic significance value.

The mild PV group (PASI score ≤ 5) showed a mean
uric acid level of 5.3286 ± 1.10970. In the moderate
PV group (PASI score 6 – 10) showed a mean uric acid
level of 6.3250 ± 1.50119. In the severe PV group
(PASI score ≥ 11) showed a mean value of 6.6786 ±
2.84394. The results of the statistical test obtained r
= 0.27, which showed a correlation value with a value
of p = 0.046, which means that there was a
significant relationship between the severity of PV
and the value of uric acid levels in the mild,
moderate, and severe PV groups. This study shows
that the higher the uric acid level, the more severe
the degree of PV (Table 4).

Table 4. Differences in the degree of severity based on the PASI score on uric acid levels.
The mean value of uric acid levels with
Number of the PASI score P value
Variable subjects
(n) Mild Moderate Severe
(PASI ≤ 5) (PASI 6 - 10) (PASI ≥ 11)
Uric acid levels
Normal (≤ 6,1) 21 4,9 5,44 4,23
0,025
High (≥ 6.2) 15 6,4 7,8 8,51
Note: PASI = psoriasis area severity index, P = asymptotic significance value

4. Discussion UV, drugs, smoking, alcohol, infections, and mental

Psoriasis vulgaris (PV) is a recurrent chronic
inflammatory skin disease characterized
erythematous, scaly, well-defined plaques.16 A 2013
Enamandram study in Massachusetts found the
prevalence of PV to range between 0.73% and 2.9% in
Europe and between 0.7% and 2.6% in the United
States.17 PV etiology can be environmental factors and
genetic factors. Environmental risk factors, including
stress, play an important role in the pathogenesis of
by psoriasis.18 Genetic risk factors demonstrated in a
2020 study by Ogawa in Osaka, Where population
studies show a greater incidence of psoriasis among
first- and second-degree relatives of patients and
patients with earlier disease onset show a more severe
course with a positive family history.19 The clinical
manifestations of PV are characterized by

755
erythematous scaly patches or plaques that generally
occur on extensor surfaces. The lesions have a
symmetrical distribution with a predilection for the
knees, elbows, scalp, and sacrum.20,21
Valenzuela et al's 2011 study in Santiago found
that the majority of PV patients were aged 30-49
years.22 Trettel et al also studied in 2017 in Hamburg
with the largest age group of PV patients aged 35-64
years.23 Hawro et al's 2017 study in Berlin used a
sample of patients with an average age of 45 years.24
The studies above are in line with research conducted
where the highest incidence of PV was found in the age
range of 46-70 years with an average age of 48.81
2.01 years.
Dewi et al. 2021 in Malang studied PV patients,
with the majority being male, as much as 57.6% and
42.4% female.6 Iskandar et al.'s 2021 study in
Manchester found that women were infected with
psoriasis at a younger age than men. There is no
consensus regarding the effect of gender differences on
the incidence and prevalence of psoriasis, but there is
a slightly higher prevalence in males.25 This is the
same as this study, which had higher male sub-
subjects (64%). Sjahrir et al. in 2018 in Medan
researched PV subjects, with the majority of patients
having suffered from PV for more than 10 years (55%).
Duration of illness is associated with the development
of complications due to PV, especially in the absence
of treatment. Comorbidity of other diseases, such as
cardiovascular disorders, psoriasis, arthritis, and
psychiatric disorders, is often associated with the
duration of PV.26 Lin et al. in 2011 in Taoyuan found
that 172 out of 480 patients had PV for more than 10
years (38.6%), 124 patients for 1-5 years (27.4%), 121
patients for 6-10 years (26, 7%) and 33 patients for 1
year (7.3%).27 This study examined subjects, with the
majority suffering from PV 0-8 years (66.7%) and the
rest suffering from PV ≥ 9 years (33.3%).
Uric acid is a weak organic acid with a pKa of 5.75,
which at physiological pH levels can be monosodium
urate. This acid is the end product of purine
degradation. Elevated urate concentrations are
detrimental to hyperuricemia and are associated with
various human diseases. Hyperuricemia is a common
finding in patients with the metabolic syndrome with
an inverse correlation between insulin resistance and
reduced renal uric acid clearance. Hyperuricemia is
also frequently observed in patients with
cardiovascular disease.28 Uric acid is the final
metabolite of nucleic acids (purines). Uric oxidase
catalyzes the conversion of uric acid to the soluble
allantoin compounds in most mammals. Uric oxidase
lost its function in the course of human and other
primate evolution, so uric acid tends to accumulate in
the human body. The concentration of uric acid in
humans is tightly regulated by reabsorption in the
proximal tubule because of its water-insoluble nature.
Uric acid precipitates and crystallizes easily when its
concentration exceeds the saturation point.29 Tao et al.
2018 in Shanghai categorize uric acid levels < 6.1
mmol/L as normal levels and ≥ 6.2 mmol/L as high
levels.30
Patients with PV have higher serum uric acid levels
than healthy individuals, and this is due to the
presence of excessive turnover of keratinocytes in
psoriatic plaques, which causes excessive production
of uric acid. Urate crystals are alarmins that stimulate
innate immunity through NALP inflammasomes and
induce potent inflammation through the production of
the cytokines interleukin (IL)-1 and IL-18. Formation
of NALP inflammasome and tumor production necrosis
factor-α, IL-1a, IL-8/chemokine (C-X-C motif) ligand 8
and IL-6 have also been shown in epidermal cells
cultured in the presence of urate crystals. These
cytokines play an important role in the pathogenesis
of plaque psoriasis through their involvement in the
immune response. Subjects with an innate immune
system that is highly sensitive to small urate crystals
may be susceptible to developing PV.29
Zhang et al.'s 2021 study in Shanghai found a
positive correlation between uric acid levels and PV,
Where patients with moderate to severe PV in Europe,
America, and Southeast Asia have higher levels of uric
acid.15 Another study by Cassano et al. in 2011 in Bari
(Italy) found a positive correlation between
significantly higher uric acid levels in PV patients.31
756
Research by Nicolae et al. in 2019 in Bucharest found
that uric acid is a risk factor for PV.32 This is in line
with the results of this study, where there is a positive
correlation between uric acid levels and the severity of
PV.
Frederiksson and Pettersson, in 1978
Skärholmen, developed the PASI to measure the
severity of PV. The PASI score includes a number of
dermatologically defined parameters, such as skin
redness and infiltration, which correspond to the
inflammatory component of the disease and allow the
assessment of areas of skin involvement. The Psoriasis
Area and Severity Index is one of the best validation
scores for determining disease severity in PV because
of its long history of use. Al-Mutairi et al. in 2010 in
Farwaniya examined the relationship between the
severity of PV through the PASI score and uric acid
levels and found a positive correlation between the
two.33,34 Menting et al.'s 2014 study in Amsterdam and
Kusakari et al.'s 2015 study in Sendai are some of the
PV-related studies that used the PASI score as a
marker of PV severity.35,36 These studies are in line
with this study, where the more severe the PV, the
higher the PASI score.
The limitations of this study are the limited number
of samples and only representing the condition of one
study center at Dr. Moewardi General Hospital.
Further research with more research subjects and
multicenter is needed to determine the effect of uric
acid levels on the severity of PV.
5. Conclusion
Psoriasis vulgaris (PV) is a chronic inflammatory
skin disease characterized by complex changes in
epidermal growth and differentiation, as well as
several biochemical, immunological, and vascular
abnormalities, which can interfere with
psychosocial sufferers. Study In this study,
significant relationship was found between uric acid
levels and the severity of PV, which was in line with an
increase in the PASI score. The higher the level of uric
acid, the more severe the degree of severity of PV.
Periodic uric acid laboratory tests are recommended in
PV patients as an early indicator of steps to prevent
the development of lesions and increased risk of
complications.
6. References
at 1. Kang S, Amagai M, Bruckner A, Fitzpatrick’s
dermatology in general medicine. 9th ed. New
York: McGraw-Hill. 2019.
2. Korman NJ. Management of psoriasis as a
systemic disease: What is the evidence? Br J
Dermatol. 2020; 182: 840–848.
3. Kanda N, Hoashi T, Saeki H. Nutrition and
psoriasis. Int J Mol Sci. 2020; 21: 5405.
4. Kamiya K, Kishimoto M, Sugai J. Risk factors
for the development of psoriasis. Int J Mol Sci.
2019; 20: 4347.
5. Armstrong AW, Mehta MD, Schupp CW.
Psoriasis prevalence in adults in the United
States. JAMA Dermatol. 2021; 157: 940–6.
6. Dewi VA, Brahmanti H, Prawitasari S. Profile
relationship with the severity of psoriasis
vulgaris patients at Dr. Saiful Anwar General
Hospital, Malang, for the period 2017-2019.
Sarjana, Universitas Brawijaya. 2022.
7. Segar D, Praharsini I, Indira IE. Prevalence and
clinical manifestations of patients with
psoriasis in Sanglah General Hospital from
2017 to 2018. Intisari Sains Medis. 2019;
10(3).
8. Boehncke W-H. Etiology and pathogenesis of
psoriasis. Rheum Dis Clin. 2015; 41: 665–75.
9. Rendon A, Schäkel K. Psoriasis pathogenesis
and treatment. Int J Mol Sci. 2019; 20: 1475.
10. Suwarsa O, Dharmadji HP, Sutedja E, Skin
tissue expression and serum level of thymic
stromal lymphopoietin in patients with
the psoriasis vulgaris. Dermatol Rep. 2019; 11:
a 8006.
11. Strober B, Ryan C, van de Kerkhof P.
Recategorization of psoriasis severity: Delphi
consensus from the International Psoriasis
Council. J Am Acad Dermatol. 2020; 82: 117–
22.
757
12. McCall CO. Psoriasis: Clinical features and 24. Hawro M, Maurer M, Weller K. Lesions on the
pathology. AJSP Rev Rep. 2011; 16: 2–9. back of hands and female gender predispose to
13. Gold LS, Hansen JB, Patel D. PGAxBSA stigmatization in patients with psoriasis. J Am
composite versus PASI: Comparison across Acad Dermatol. 2017; 76: 648-54.e2.
disease severities and as therapeutic response 25. Iskandar IYK, Parisi R, Griffiths CEM.
measure for Cal/BD foam in plaque psoriasis. Systematic review examining changes over time
J Am Acad Dermatol. 2020; 83: 131–8. and variation in the incidence and prevalence
14. Lai YC, Yew YW. Psoriasis and uric acid: A of psoriasis by age and gender*. Br J Dermatol.
population-based cross-sectional study. Clin 2021; 184: 243–58.
Exp Dermatol. 2016; 41: 260–6. 26. Sjahrir M, Effendy E, Roesyanto ID.
15. Zhang Y, Liu L, Sun X. Updated evidence of the Comparison of brain-derived neurotrophic
association between elevated serum uric acid factor levels of psoriasis vulgaris patients and
level and psoriasis. Front Med. 2021; 8: non-psoriasis vulgaris patients | Media
645550. Dermato Venereologica Indonesiana. 2018;
16. Parisi R, Iskandar I, Kontopantelis E. National, 45(1).
regional, and worldwide epidemiology of 27. Lin T-Y, See L-C, Shen Y-M. Quality of life in
psoriasis: Systematic analysis and modelling patients with psoriasis in northern Taiwan.
study on behalf of the Global Psoriasis Atlas. Chang Gung Med J. 2011; 34: 186–96.
BMJ. 2020; 369: 1590. 28. So A, Thorens B. Uric acid transport and
17. Enamandram M, Kimball AB. Psoriasis disease. J Clin Invest. 2010; 120: 1791–9.
epidemiology: The interplay of genes and the 29. Tsuruta N, Imafuku S, Narisawa Y.
environment. J Invest Dermatol. 2013; 133: Hyperuricemia is an independent risk factor for
287–9. psoriatic arthritis in psoriatic patients. J
18. Zeng J, Luo S, Huang Y. Critical role of Dermatol. 2017; 44: 1349–52.
environmental factors in the pathogenesis of 30. Tao M, Pi X, Ma X. Relationship between serum
psoriasis. J Dermatol. 2017; 44: 863–72. uric acid and clustering of cardiovascular
19. Ogawa K, Okada Y. The current landscape of disease risk factors and renal disorders among
psoriasis genetics in 2020. J Dermatol Sci. Shanghai population: A multicentre and cross-
2020; 99: 2–8. sectional study. BMJ Open. 2019; 9: e025453.
20. Armstrong AW, Read C. Pathophysiology, 31. Cassano N, Carbonara M, Panaro M. Role of
clinical presentation, and treatment of serum uric acid in conditioning the association
psoriasis: A review. JAMA. 2020; 323: 1945– of psoriasis with metabolic syndrome. Eur J
60. Dermatol. 2011; 21: 808–9.
21. Sarac G, Koca TT, Baglan T. A brief summary 32. Nicolae I, Tampa M, Ene CD. Correlations
of clinical types of psoriasis. North Clin Istanb. between related-purine derivatives and renal
2016; 3: 79–82. disorders in patients with psoriasis vulgaris.
22. Valenzuela F, Silva P, Valdés MP. Epidemiology Exp Ther Med. 2019; 17: 1012–9.
and quality of life of patients with psoriasis in 33. Al-Mutairi N, Al-Farag S, Al-Mutairi A.
Chile. Actas Dermosifiliogr. 2011; 102: 810–6. Comorbidities associated with psoriasis: an
23. Trettel A, Spehr C, Körber A. The impact of age experience from the Middle East. J Dermatol
on psoriasis health care in Germany. J Eur 2010; 37: 146–55.
Acad Dermatol Venereol JEADV. 2017; 31: 34. Oji V, Luger TA. The skin in psoriasis:
870–5. assessment and challenges. Clin Exp

758
 Rheumatol. 2015; 33: S14-19.
35. Kusakari Y, Yamasaki K, Takahashi T.
Successful adalimumab treatment of a
psoriasis vulgaris patient with hemodialysis for
renal failure: A case report and a review of the
previous reports on biologic treatments for
psoriasis patients with hemodialysis for renal
failure. J Dermatol. 2015; 42: 727–30.
36. Menting SP, Sitaram AS, Bonnerjee‐van der
Stok HM. Drug survival is not significantly
different between biologics in patients with
psoriasis vulgaris: a single‐centre database
analysis. Br J Dermatol. 2014; 171: 875–83.

759