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        "titulo" => "Validaci&#243;n de la versi&#243;n espa&#241;ola del cuestionario PURE-4 para la detecci&#243;n precoz de la artritis psori&#225;sica en pacientes con psoriasis"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Psoriasis is an inflammatory and immunomediated dermatological disease that affects approximately 1&#37; to 3&#37; of adults in Western Europe&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">1</span></a> Psoriasis can be associated with various comorbidities&#44; including psoriatic arthritis &#40;PsA&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">2</span></a> The estimated prevalence of PsA ranges from 0&#46;05&#37; up to 0&#46;25&#37; in the general population and from 6&#37; up to 41&#37; in psoriatic patients&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">3</span></a> Overall&#44; psoriasis appears before the clinical signs of PsA&#44;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">4&#44;5</span></a> which explains why dermatologists are often the first specialists to face the challenge of identifying patients at risk of developing PsA&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The estimated prevalence of undiagnosed PsA among psoriatic patients is between 15&#37; up to 40&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">4&#44;6&#44;7</span></a> Diagnosis is complex and is usually confirmed after several years&#44; highlighting gaps in detection and intervention&#44; when early treatment is known to improve clinical and health outcomes&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">8</span></a> Therefore&#44; the identification of PsA among psoriatic patients is crucial&#44; as it would facilitate rapid referral to the rheumatologist after the onset of the first symptoms&#46; Dermatologists have been recommended to closely monitor signs of PsA in psoriatic patients&#44; at least&#44; once a year and&#44; ideally&#44; every 6 months&#44; conducting a complete physical examination to check for peripheral inflammation and dactylitis&#44; enthesitis&#44; and inflammatory axial pain&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">9</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">With the aim of facilitating the early detection of PsA in dermatology clinics&#44; a simple tool&#44; the Psoriatic Arthritis UnclutteRed Screening Evaluation &#40;PURE-4&#41; questionnaire&#44; was developed and validated in a French population with psoriasis&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">10</span></a> The strengths of PURE-4 include its feasibility in clinical practice&#44; good discriminatory ability&#44; and high sensitivity and specificity rates &#40;85&#46;7&#37; and 83&#46;6&#37;&#44; respectively&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">10</span></a> The questionnaire has been culturally adapted into Spanish language following standard methodology&#44;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">11</span></a> and experts recommend its use due to the reduced number of items&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">9</span></a> The objective of this study is to validate the Spanish version of PURE-4 in terms of sensitivity&#44; specificity&#44; feasibility&#44; reliability&#44; and construct validity&#46; Additionally&#44; its electronic version with a virtual assistant &#40;chatbot&#41; was evaluated&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Study design and participants</span><p id="par0020" class="elsevierStylePara elsevierViewall">We conducted an observational and multicenter study among 19 Spanish hospitals&#44; with 2 cross-sectional evaluations&#46; Evaluation &#35;1 included psoriatic patients&#44; without a diagnosis of PsA&#44; and was performed by dermatologists and rheumatologists during routine visits&#46; Evaluation &#35;2 included patients without a diagnosis of PsA &#40;in evaluation &#35;1&#41; and was performed by the same rheumatologists 1 year later &#40;&#177; 2 months&#41; to determine the presence of PsA &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The results of evaluation &#35;2 are not included in this article&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">From November 15 through December 30&#44; 2020&#44; adult patients with psoriasis without a previous diagnosis of PsA who could respond to the PURE-4 questionnaire in paper and electronic formats were recruited&#46; Considering that the probability of finding PsA in patients with moderate-to-severe psoriasis increases&#44; and to ensure a PsA prevalence of 15&#37;&#44; at least&#44; 60&#37; of included patients should have moderate-to-severe psoriasis &#40;Psoriasis Area and Severity Index &#91;PASI&#93; &#8805;7&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">12&#44;13</span></a> All participants gave their prior written informed consent before recruitment&#46; The study was approved by Hospital de Bellvitge Ethics Committee &#40;reference PR384&#47;20 &#91;CSI 20&#47;89&#93;&#41; and was conducted following the principles described in the Declaration of Helsinki&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Procedures</span><p id="par0030" class="elsevierStylePara elsevierViewall">The first visit to the dermatologist was followed by an independent visit to the rheumatologist &#40;ideally&#44; on the same day&#44; or within 4 weeks following the dermatologist&#39;s visit&#41;&#46; At the time of inclusion&#44; demographic and clinical data were recorded &#40;see <a class="elsevierStyleCrossRef" href="#sec0080">Appendix A&#44; &#8220;Supplementary Methods&#44;&#8221; in the supplementary data</a>&#41;&#44; and patients completed the paper version of the PURE-4&#46; Before concluding the visit&#44; the dermatologist provided the patient with the electronic version of the PURE-4 and collected the patient&#39;s opinions and preferences regarding the paper and electronic versions of the questionnaire&#46; Subsequently&#44; the rheumatologist&#44; blinded to the PURE-4 results&#44; assessed the presence&#47;absence of PsA based on the patient&#39;s health history and examination&#46; When additional tests were necessary for the diagnosis of PsA according to clinical practice&#44; an additional 2 months were allowed for confirmation purposes&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">PURE-4 Questionnaire</span><p id="par0035" class="elsevierStylePara elsevierViewall">The PURE-4 questionnaire consists of 4 questions with affirmative or negative answers about signs of dactylitis&#44; inflammatory heel pain&#44; bilateral buttock pain&#44; and peripheral joint pain with inflammation before the age of 50 &#40;see <a class="elsevierStyleCrossRef" href="#sec0080">Appendix A&#44; Figure S1 of the supplementary data</a>&#41;&#46; Each positive response scores 1 point&#44; with the maximum score being the sum of &#8220;Yes&#8221; responses &#40;0 to 4 points&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">10</span></a> An electronic version of the PURE-4 questionnaire in Spanish was also evaluated&#44; supported by a chatbot or virtual assistant&#44; with information and images explaining the meaning of the items&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Study outcomes</span><p id="par0040" class="elsevierStylePara elsevierViewall">The performance of the Spanish paper version of the PURE-4 questionnaire was examined&#44; with the clinical diagnosis being confirmed by the rheumatologist as the reference&#46; Patient perceptions &#40;simple&#44; quick&#44; comfortable&#44; and useful&#41; of the paper and electronic versions were compared using a visual analog scale from 0 up to 10&#44; as well as patient preferences between both versions&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Data analysis</span><p id="par0045" class="elsevierStylePara elsevierViewall">Data are expressed as mean &#177; standard deviation &#40;or median and interquartile range&#41; for quantitative variables and as frequencies and percentages for categorical variables&#46; Comparisons between participants with and without PsA were made using the Student&#39;s t-test&#44; Fisher&#39;s exact test&#44; and the Mantel-Haenszel test&#44; as appropriate&#46; The receiver operating characteristic &#40;ROC&#41; curve and the area under the curve &#40;AUC&#41; were used to evaluate the performance of PURE-4 in detecting PsA&#44; and validity&#44; sensitivity&#44; specificity&#44; positive predictive value&#44; negative predictive value&#44; and Youden&#39;s index were analyzed to find the optimal cutoff value for patient classification&#46; Additional validation tests are described in <a class="elsevierStyleCrossRef" href="#sec0080">Appendix A&#44; &#8220;Supplementary Methods&#8221; of the supplementary data</a>&#46; The intraclass correlation coefficient &#40;ICC&#41; was used to assess internal consistency between paper and electronic versions of the questionnaire&#46; Statistical analyses were performed using SAS software version 7&#46;15&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Results</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Study participants and clinical evaluations</span><p id="par0050" class="elsevierStylePara elsevierViewall">A total of 283 psoriatic patients were recruited&#59; 3 were excluded for having PsA or another rheumatologic condition&#44; and 12 because they did not attend their rheumatology appointment&#46; The final analysis included a total of 268 patients &#40;115 &#91;42&#46;9&#37;&#93; women&#59; mean age&#44; 47&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#46;6&#41;&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the demographic and clinical data of patients with and without PsA&#46; The mean PASI score was 7&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;1&#46; A total of 238 &#40;88&#46;8&#37;&#41; patients were on active treatment for psoriasis&#46; The mean time between dermatology and rheumatology visits was 1&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;6 weeks&#46; In evaluation &#35;1&#44; the prevalence of PsA based on the rheumatologist&#39;s diagnosis was 12&#46;7&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>34&#41;&#59; it was not possible to confirm or rule out the diagnosis of PsA in 11 patients&#44; even after obtaining additional test results within this period&#46; Overall&#44; the most common psoriasis locations were the extremities and flexural areas &#40;PsA&#44; 85&#46;3&#37; vs non-PsA&#44; 78&#46;5&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;360&#41;&#44; trunk &#40;PsA&#44; 50&#46;0&#37; vs non-PsA&#44; 54&#46;7&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;608&#41;&#44; and difficult-to-treat locations &#40;PsA&#44; 67&#46;6&#37; vs non-PsA&#44; 48&#46;0&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;033&#41;&#46; Information on inflammatory signs&#44; imaging findings&#44; and additional tests is shown in <a class="elsevierStyleCrossRef" href="#sec0080">Appendix A&#44; Table S1 of the supplementary data</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a> illustrates the distribution of current psoriasis treatment among patients with and without PsA&#46; Biological therapy was received by 25&#46;8&#37; of patients with PsA vs 46&#46;0&#37; of patients without PsA &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;035&#41;&#44; while topical treatments were used by 61&#46;3&#37; vs 32&#46;8&#37;&#44; respectively &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;002&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Questionnaire responses and screening results</span><p id="par0060" class="elsevierStylePara elsevierViewall">All patients completed the PURE-4 questionnaire on paper&#46; <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the mean PURE-4 score among patients with PsA as 2&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;1&#44; and 1&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;3 among patients without a diagnosis of PsA &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; Peripheral joint pain with inflammation before the age of 50 was the item most frequently answered affirmatively by 137 &#40;51&#46;1&#37;&#41; patients &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Using the Youden index&#44; the optimal cutoff value was &#8805;<span class="elsevierStyleHsp" style=""></span>2&#44; with the highest percentage of properly classified patients&#44; showing a sensitivity rate of 79&#46;4&#37; &#40;95&#37; confidence interval &#91;CI&#93;&#44; 63&#46;2-89&#46;7&#41; and a specificity rate of 61&#46;4&#37; &#40;95&#37;CI&#44; 54&#46;9-67&#46;6&#37;&#41; for detecting PsA &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; A total of 63&#46;8&#37; of patients were classified the same by the PURE-4 questionnaire and the rheumatologist&#44; with a negative predictive value of 95&#46;1&#37;&#46; The ROC curve showed an AUC of 0&#46;729 &#40;95&#37;CI&#44; 0&#46;649-0&#46;809&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#44; indicating good performance of PURE-4&#46; Patient distribution based on the PURE-4 results is shown in <a class="elsevierStyleCrossRef" href="#sec0080">Appendix A&#44; Figure S2 of the supplementary data</a>&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">The internal consistency of the PURE-4 questionnaire obtained a Cronbach&#39;s &#945; value of 0&#46;610&#44; indicative of good consistency&#46; Supplementary data &#40;<a class="elsevierStyleCrossRef" href="#sec0080">Appendix A&#44; Table S2 of the supplementary data</a>&#41; describes the relationship between the PURE-4 score and the clinical variables evaluated by rheumatologists &#40;dactylitis&#44; enthesitis&#44; inflammatory back pain&#44; and peripheral joint pain&#41;&#44; all of which were statistically significant &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; The mean PURE-4 score &#40;2&#46;19<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;29&#41; was significantly higher in patients who met the CASPAR criteria than in those who did not &#40;1&#46;29<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;26&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;002&#41;&#46; The agreement percentage between both diagnostic criteria &#40;PURE-4 and CASPAR&#41; was 61&#46;4&#37;&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Paper and electronic versions of the PURE-4 questionnaire</span><p id="par0075" class="elsevierStylePara elsevierViewall">For the comparison of both questionnaire versions&#44; a total of 280 patients with available information were included&#46; A total of 98&#46;9&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>277&#41; of those who completed both versions of the questionnaire&#44; and only 16 respondents &#40;5&#46;8&#37;&#41; needed help from the virtual assistant&#46; Responses to both versions of the PURE-4 questionnaire showed good correlation &#40;ICC<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;965&#41; and both were considered simple&#44; quick&#44; comfortable&#44; and useful tools&#44; although the paper questionnaire received slightly higher ratings &#40;<a class="elsevierStyleCrossRef" href="#sec0080">Appendix A&#44; Table S3 of the supplementary data</a>&#41;&#46; More patients preferred the paper &#40;39&#46;0&#37;&#41; than the electronic version &#40;27&#46;6&#37;&#41;&#59; one third of respondents rated both options equally &#40;33&#46;5&#37;&#41;&#46;</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Discussion</span><p id="par0080" class="elsevierStylePara elsevierViewall">This study was motivated by the need to address the challenge of early recognition of PsA by dermatologists treating psoriatic patients&#46; Based on results&#44; the performance of the PURE-4 questionnaire was slightly better than that reported for other PsA screening tools such as the Psoriatic Arthritis Screening Evaluation &#40;PASE&#41;&#44; the Psoriasis Epidemiology Screening Tool &#40;PEST&#41;&#44; the Toronto Psoriatic Arthritis Screen &#40;ToPAS&#41;&#44; or the CONTEST questionnaire&#44;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">14&#44;15</span></a> although diagnostic accuracy shows great heterogeneity across screening tools&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">16</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">The ROC curve analysis showed good negative predictive values for detecting PsA&#44; indicating that the PURE-4 questionnaire is suitable for use as an initial screening tool&#44; albeit with some probability of false positive results&#46; Therefore&#44; patients with a score above the cutoff value &#40;&#62;<span class="elsevierStyleHsp" style=""></span>2&#41; should undergo formal rheumatological examination to verify the diagnosis of PsA&#44; which is consistent with the nature of a screening test&#46; There are several benefits associated with the PURE-4 questionnaire&#58; it is a rapid and useful screening method in busy clinics&#59; it streamlines referral to rheumatology&#44; eventual confirmation of PsA&#44;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">9</span></a> and increases the likelihood of patients receiving appropriate treatment to reduce deterioration in their quality of life&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">17</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">In our cohort&#44; the prevalence of PsA was 12&#46;7&#37;&#44; which is similar to the one seen in the validation study conducted by Audureau et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">10</span></a> although they used CASPAR criteria as the reference&#46; Although psoriasis severity and duration seem to increase the risk of developing PsA&#44;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">18&#44;19</span></a> in our study&#44; psoriasis severity was similar between those with and without PsA&#44; except for difficult-to-treat areas&#44; which were more common in those with PsA&#46; Additionally&#44; quality of life&#44; assessed by the Dermatology Life Quality Index&#44; was more affected in patients with PsA&#46; Recent data indicate that biological therapies could also have an impact on the incidence of PsA&#44; decreasing or delaying joint involvement&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">20&#8211;22</span></a> Our results showed that patients on biological therapy had a lower frequency of PsA&#46; Nonetheless&#44; actively seeking signs of PsA&#44; at least&#44; once a year and&#44; ideally&#44; every 6 months is advisable&#44;9 regardless of the patient&#39;s treatment or psoriasis severity&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Digital tools can encourage patient self-care and facilitate more effective communication between patients and doctors&#44; improving long-term clinical management&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">23</span></a> In this context&#44; the use of new technologies represents a valuable facilitator for implementing digital screening for PsA&#44;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">24</span></a> allowing more active monitoring of patients with psoriasis&#46; The electronic version of the PURE-4 questionnaire showed high correlation &#40;ICC<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;963&#41; with the conventional questionnaire&#46; This tool could facilitate the remote detection of joint symptoms&#44; in a simple and quick manner&#46; Since timely treatment can reduce cutaneous symptoms&#44; pain&#44; and subclinical inflammation&#44;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">25&#44;26</span></a> an accurate detection method has the potential to change the clinical course of PsA&#46; Earlier intervention can prevent arthritis progression&#44; reduce flares&#44; and thus improve disease control and quality of life&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">27</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">The limitations of this study are as follows&#58; although the two modalities of the Spanish version of the PURE-4 questionnaire could be used to facilitate PsA detection&#44; the results are applicable to the Spanish context and may not be generalizable to other countries&#46; Additionally&#44; to minimize selection bias&#44; all participants completed the PURE-4 questionnaire regardless of the presence or absence of PsA signs&#44; albeit without confirmed clinical diagnosis&#46; While this could be perceived as a limitation of the patient flow in dermatology clinics&#44; the present study was designed for PURE-4 validation for early PsA detection following linguistic adaptation&#46;11 Therefore&#44; it was established that&#44; at least&#44; 60&#37;12 of the sample should have moderate-to-severe psoriasis&#44; defined by a PASI<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>7&#44;13 as moderate-to-severe psoriasis presents a higher risk of developing PsA&#46;5 Furthermore&#44; 43&#37; of patients were on biological therapy&#44; which likely reduced PsA-related incidence&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">20&#8211;22&#44;28</span></a> Another limitation&#44; affecting only the comparison between paper and electronic versions of PURE-4&#44; is the fact that patients completed both versions in the same visit and order&#44; which may have introduced a recall bias in electronic questionnaire responses&#46; However&#44; this does not have an impact on the main objective of the study&#44; as the paper version was always administered first&#44; eliminating the learning effect&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">In conclusion&#44; the Spanish version of the PURE-4 questionnaire has been validated using rigorous methods in terms of sensitivity&#44; specificity&#44; feasibility&#44; and construct validity for PsA screening&#46; The optimal cutoff value was &#8805;<span class="elsevierStyleHsp" style=""></span>2&#44; with acceptable internal consistency&#46; Both paper and electronic versions were highly rated by the patients&#44; with similar proportions of patients preferring the paper&#44; electronic&#44; or the two versions&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Therefore&#44; this questionnaire could guide early referral to rheumatology&#44; reducing delay in PsA diagnosis and treatment&#46; This tool should be considered as a supplement for dermatologists when exploring signs and symptoms of PsA in psoriatic patients&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Funding</span><p id="par0115" class="elsevierStylePara elsevierViewall">This study was funded by Novartis Farmac&#233;utica S&#46;A&#46;&#44; Spain&#44; following good publication practices &#40;GPP-2022&#41;&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Conflicts of interest</span><p id="par0120" class="elsevierStylePara elsevierViewall">Isabel Belinch&#243;n Romero has received consultant and&#47;or speaker &#8216;s fees and participated in clinical trials sponsored by the following pharmaceutical companies whose therapeutic arsenal includes drugs used to treat psoriasis&#58; Janssen Pharmaceuticals Inc&#44; Almirall SA&#44; Lilly&#44; AbbVie&#44; Novartis&#44; Celgene&#44; Biogen&#44; Amgen&#44; Leo-Pharma&#44; Pfizer-Wyeth&#44; BMS&#44; UCB&#44; and MSD&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Ana L&#243;pez-Ferrer has received fees for her participation as a member of scientific committees&#44; consultant and&#47;or speaker&#39;s fees&#44; and research grants or participated in clinical trials sponsored by the following pharmaceutical companies &#40;unrelated to this manuscript though&#41;&#58; AbbVie&#44; Almirall&#44; Amgen&#44; Janssen&#44; LEO Pharma&#44; MSD&#44; Eli Lilly&#44; Novartis&#44; and UCB Pharma&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Marta Ferr&#225;n i Farr&#233;s has received consultant and&#47;or speaker&#39;s fees and participated in clinical trials sponsored by the following pharmaceutical companies&#58; Janssen Pharmaceuticals Inc&#44; Eli Lilly&#44; Novartis&#44; Pfizer-Wyeth&#44; MSD&#44; AbbVie&#44; Celgene&#44; and Almirall SA&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Raquel Rivera D&#237;az has received consultant and&#47;or speaker&#39;s fees and participated in clinical trials sponsored by the following pharmaceutical companies&#58; AbbVie&#44; Almirall SA&#44; Celgene&#44; GSK&#44; Janssen Pharmaceuticals Inc&#44; Eli Lilly&#44; Leo-Pharma&#44; MSD&#44; Novartis&#44; Pfizer-Wyeth&#44; and UCB&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">David Vidal Sarro has received consultant and&#47;or speaker&#39;s fees and participated in clinical trials sponsored by the following pharmaceutical companies&#58; AbbVie&#44; Celgene&#44; Eli Lilly&#44; Janssen Pharmaceuticals Inc&#44; Novartis&#44; Gebro Pharma&#44; Leo-Pharma&#44; and UCB&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Lourdes Rodr&#237;guez Fern&#225;ndez-Freire has received consultant&#39;s fees and&#47;or fees from the following pharmaceutical companies&#58; AbbVie&#44; Janssen Pharmaceuticals Inc&#44; MSD&#44; Pfizer-Wyeth&#44; Novartis&#44; Celgene&#44; Almirall SA&#44; Eli Lilly&#44; and Leo-Pharma&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Pablo de la Cueva Dobao has received consultant and&#47;or speaker&#39;s fees and participated in clinical trials sponsored by the following pharmaceutical companies&#58; AbbVie&#44; Almirall SA&#44; Astellas Pharma&#44; Biogen Inc&#46;&#44; Boehringer Ingelheim&#44; Celgene&#44; Janssen Pharmaceuticals Inc&#44; LEO Pharma&#44; Eli Lilly&#44; MSD&#44; Novartis&#44; Pfizer&#44; and UCB&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Jorge Santos Juanes has received consultant and&#47;or speaker&#39;s fees from the following pharmaceutical companies&#58; Novartis&#44; Eli Lilly&#44; Janssen Pharmaceuticals Inc&#44; AbbVie&#44; Amgen&#44; and Sanofi&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Vicen&#231; Rocamora Duran has received consultant and&#47;or speaker&#39;s fees from the following pharmaceutical companies&#58; Janssen Pharmaceuticals Inc&#44; Eli Lilly&#44; AbbVie&#44; Almirall&#44; Amgen&#44; and Novartis&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">V&#237;ctor Mart&#237;n V&#225;zquez and Lara G&#243;mez Labradror are employees of Novartis in Spain&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Ruben Queiro has received consultant and speaker&#39;s fess and works as project coordinator of the following pharmaceutical companies&#58; Abbvie&#44; Lilly&#44; UCB&#44; Janssen&#44; Pfizer&#44; Amgen&#44; Novartis&#46; Additionally&#44; he has received grants from Janssen&#44; Novartis&#44; and Abbvie&#46;</p></span></span>"
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    "fechaRecibido" => "2023-11-20"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Background and objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Psoriasis often precedes the onset of psoriatic arthritis &#40;PsA&#41;&#44; so dermatologists often face the challenge of early identifying signs of PsA in patients with psoriasis&#46; Our aim was to validate the Spanish version of the PURE-4 questionnaire as a screening tool for PsA&#44; evaluate its performance in terms of sensitivity&#44; specificity&#44; feasibility&#44; reliability&#44; and build validity&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">This was a cross-sectional&#44; observational&#44; multicenter trial of adult patients with psoriasis&#46; Initially&#44; patients were assessed by a dermatologist and completed 2 self-administered versions &#40;in print and online&#41; of the PURE-4 questionnaire&#46; Afterwards&#44; the rheumatologist&#44; blinded to the PURE-4 results&#44; assessed the presence&#47;absence of PsA&#44; being the reference to determine the performance of the PURE-4 questionnaire&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A total of 268 patients were included &#40;115 &#91;42&#46;9&#37;&#93; women&#59; mean age&#44; 47&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#46;6&#41;&#46; The prevalence of PsA according to rheumatologist diagnosis was 12&#46;7&#37; &#40;34 patients&#41;&#46; The mean PURE-4 score for patients with psoriasis diagnosed with PsA was 2&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;1&#44; and 1&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;3 for patients without PsA &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46; The cutoff value &#8805;<span class="elsevierStyleHsp" style=""></span>2 demonstrated the best performance for detecting PsA&#44; with a negative predictive value of 95&#46;1&#37; &#40;95&#37; confidence interval&#44; 90&#46;3-97&#46;6&#41;&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The PURE-4 questionnaire demonstrated good performance in detecting PsA&#44; with an optimal cutoff point &#8805;<span class="elsevierStyleHsp" style=""></span>2&#46; This simple tool could facilitate early referral of patients to the rheumatology unit&#46;</p></span>"
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        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Antecedentes y objetivo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La psoriasis suele preceder a la aparici&#243;n de la artritis psori&#225;sica &#40;APs&#41;&#44; por lo que los dermat&#243;logos suelen enfrentarse al reto de identificar precozmente los signos de APs en pacientes con psoriasis&#46; El objetivo fue validar la versi&#243;n espa&#241;ola del cuestionario PURE-4 como herramienta de cribado para la APs&#44; evaluando su rendimiento en t&#233;rminos de sensibilidad&#44; especificidad&#44; viabilidad&#44; fiabilidad y validez de constructo&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">M&#233;todos</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se realiz&#243; un estudio transversal&#44; observacional y multic&#233;ntrico en pacientes adultos con psoriasis&#46; Inicialmente&#44; los pacientes fueron evaluados por un dermat&#243;logo y completaron dos versiones autoadministradas &#40;en papel y electr&#243;nica&#41; del cuestionario PURE-4&#46; Despu&#233;s&#44; el reumat&#243;logo&#44; ciego a los resultados del PURE-4&#44; evalu&#243; la presencia&#47;ausencia de APs&#44; siendo la referencia para determinar el rendimiento del cuestionario PURE-4&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Resultados</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron 268 pacientes &#40;115 &#91;42&#44;9&#37;&#93; mujeres&#59; edad media&#44; 47&#44;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#44;6 a&#241;os&#41;&#46; Se diagnostic&#243; de APs a 34 pacientes &#40;12&#44;7&#37;&#41; en una media &#40;DE&#41; de 1&#44;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;6 semanas&#46; La puntuaci&#243;n PURE-4 media para los pacientes con psoriasis diagnosticados de APs fue de 2&#44;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;1&#44; y de 1&#44;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;3 para los pacientes sin APs &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; El punto de corte &#243;ptimo con mejor rendimiento para detectar APs fue &#8805;<span class="elsevierStyleHsp" style=""></span>2 respuestas positivas&#44; con valor predictivo negativo del 95&#44;1&#37; &#40;intervalo de confianza 95&#37;&#58; 90&#44;3-97&#44;6&#41;&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conclusiones</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">El cuestionario PURE-4 demostr&#243; un buen rendimiento para el cribado de APs&#44; con un punto de corte &#243;ptimo &#8805;<span class="elsevierStyleHsp" style=""></span>2&#46; Esta sencilla herramienta podr&#237;a facilitar la derivaci&#243;n temprana de los pacientes al servicio de reumatolog&#237;a&#46;</p></span>"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Study schematic&#46;</p> <p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">&#42;When additional tests were required for the diagnosis of PsA according to clinical practice&#44; an additional 2 months were allowed to confirm the diagnosis of PsA&#46;</p> <p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Dx&#44; diagnosis&#59; PsA&#44; psoriatic arthritis&#46;</p>"
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          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Responses given to each item of the PURE-4&#46;</p> <p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Dx&#44; diagnosis&#59; PsA&#44; psoriatic arthritis&#59; PURE-4&#44; Psoriatic Arthritis UnclutteRed screening Evaluation&#46; &#42; p &#60; 0&#46;05&#46;</p>"
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          "leyenda" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">BSA&#44; body surface area&#59; CASPAR&#44; Classification Criteria for Psoriatic Arthritis&#59; DLQI&#44; Dermatology Life Quality Index&#59; PASI&#44; Psoriasis Area Severity Index&#59; PGA&#44; Physician&#39;s Global Assessment&#59; PsA&#44; psoriatic arthritis&#59; SD&#44; standard deviation&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Variable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Overall population&#40;N &#61; 268&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Diagnosed with PsA&#40;N&#61;34&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Without PsA Diagnosis &#40;N&#61;223&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Gender&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Female</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">115 &#40;42&#46;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14 &#40;41&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">96 &#40;43&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;837&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Age&#44; mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">47&#46;1 &#40;12&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">50&#46;8 &#40;10&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">46&#46;3 &#40;12&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;039&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Educational level&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Basic literacy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#40;1&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;4&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;1&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;570&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Primary level&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36 &#40;16&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;20&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">29 &#40;15&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Secondary level&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">78 &#40;35&#46;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;29&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">66 &#40;35&#46;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Higher education&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">99 &#40;45&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11 &#40;45&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">87 &#40;47&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Years since diagnosis&#44; mean &#40;SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&#46;6 &#40;12&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20&#46;2 &#40;14&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&#46;3 &#40;12&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;514&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">PASI score&#44; mean &#40;SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;2 &#40;5&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#46;4 &#40;5&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;0 &#40;5&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;197&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Mild &#40;PASI &#60; 7&#41;&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">111 &#40;41&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11 &#40;31&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">95 &#40;42&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;279&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Moderate-to-severe &#40;PASI &#8805; 7&#41;&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">157 &#40;58&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24 &#40;68&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">131 &#40;58&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Psoriasis location&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Face&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">39 &#40;14&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;23&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">31 &#40;13&#46;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">0&#46;145&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Neck&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">13 &#40;4&#46;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3 &#40;8&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">10 &#40;4&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;282&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Trunk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">141 &#40;52&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">17 &#40;50&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">122 &#40;54&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;608&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Back&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">100 &#40;37&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13 &#40;38&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">84 &#40;37&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;949&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Extremities and flexures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">214 &#40;79&#46;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">29 &#40;85&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">175 &#40;78&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;360&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Difficult-to-treat areas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">136 &#40;50&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23 &#40;67&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">107 &#40;48&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;033&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace"><span class="elsevierStyleItalic">-</span></span>Palmoplantar psoriasis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25 &#40;18&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 &#40;26&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18 &#40;16&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;299&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace"><span class="elsevierStyleItalic">-</span></span>Nail psoriasis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">62 &#40;45&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11 &#40;47&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">49 &#40;45&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;859&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace"><span class="elsevierStyleItalic">-</span></span>Scalp psoriasis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">110 &#40;80&#46;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20 &#40;87&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">86 &#40;80&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;460&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Others&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15 &#40;5&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;2&#46;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13 &#40;5&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;489&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">BSA value &#40;0&#37; to 100&#37;&#41;&#44; mean &#40;SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#46;7 &#40;8&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#46;3 &#40;7&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#46;5 &#40;8&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;107&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">PGA category&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>0&#46; Clearance&#44; no signs of psoriasis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18 &#40;8&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;6&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15 &#40;8&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;165&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>1&#46; Almost clear&#44; minimal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">40 &#40;18&#46;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;9&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">35 &#40;20&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>2&#46; Mild&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">59 &#40;27&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;25&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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