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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 &#8211; a chronic inflammatory skin disease &#8211; represents a significant burden fir global health worldwide&#44; affecting millions of people<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">1</span></a> and predisposing individuals to comorbidities such as cardiovascular diseases&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">2&#44;3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Despite its widespread impact&#44; psoriasis shows considerable geographical variation in prevalence&#44; ranging from 0&#46;14&#37; in East Asia up to 1&#46;99&#37; in Australasia&#44; with particularly high rates in Western Europe&#44; Central Europe&#44; North America and high-income countries in southern Latin America&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">While recent research suggests a stable or slightly decreasing trend in the overall incidence of psoriasis&#44;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">5&#8211;9</span></a> prevalence data consistently shows an increase&#46;<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">8&#44;10</span></a> Paradoxically&#44; despite a 27&#37; increase in diagnosed cases worldwide from 1990 through 2019&#44; the age-standardised incidence rate &#40;ASIR&#41; showed a slight decline of &#8722;0&#46;77&#37; per year&#44; which was consistent across sexes&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">11</span></a> This discrepancy highlights the need for further research into the drivers of this trend&#44; including increased awareness&#44; improved diagnostics&#44; demographic changes or environmental influences&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Former studies have predominantly analyzed the incidence of psoriasis using unadjusted age and rarely examined the effects of age&#44; period and cohort&#46; The declining trend raises questions about its correlation with changes across calendar periods or birth cohorts&#44; regardless of population ageing&#46; Age-period-cohort &#40;A-P-C&#41; analysis is emerging as an important tool to uncover independent effects on the incidence of the disease by considering patient age&#44; period&#44; birth cohort and other influential factors typically omitted in cross-sectional studies&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In Spain&#44; the estimated prevalence of psoriasis increased from 1&#46;4&#37; in 2001 up to 2&#46;3&#37; in 2013&#44; based on telephone surveys&#46;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">12&#44;13</span></a> This increase has been attributed to factors such as evolving diagnostic criteria&#44; increased awareness and improved reporting systems&#44; with the introduction of biologic therapies potentially affecting prevalence and patient outcomes&#46; Unfortunately&#44; the lack of studies on the incidence of psoriasis in Spain complicates understanding these dynamics&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">4</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">This study aims to fill this gap by examining the incidence of psoriasis in Spain from 1990 through 2019 using the Global Burden of Disease &#40;GBD&#41; database<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">14&#44;15</span></a> and the A-P-C analysis<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">16&#8211;18</span></a> to disentangle the impact of age&#44; historical period&#44; and birth cohort on the incidence of psoriasis in Spain&#46; This will provide a more comprehensive understanding of the dynamics of psoriasis in this region&#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</span><p id="par0035" class="elsevierStylePara elsevierViewall">We conducted an ecological trend study to analyze the incidence of psoriasis in Spain from 1990 through 2019&#46; This study was conducted following the Strengthening the Reporting of Observational Studies in Epidemiology &#40;STROBE&#41; statement to improve the quality of reporting and ensure methodological transparency &#40;<a href="https://www.equator-network.org/reporting-guidelines/strobe/">https&#58;&#47;&#47;www&#46;equator-network&#46;org&#47;reporting-guidelines&#47;strobe&#47;</a>&#41;&#46;</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Data sources</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Incidence of psoriasis</span><p id="par0040" class="elsevierStylePara elsevierViewall">Cases of psoriasis were defined using the International Classification of Diseases &#40;ICD&#41;-10 codes L40 and L41&#46; Data on the incidence of psoriasis&#44; stratified by age group and sex&#44; were obtained from the Institute for Health Metrics and Evaluation GBD Results Tool &#40;<a href="https://vizhub.healthdata.org/gbd-results/">https&#58;&#47;&#47;vizhub&#46;healthdata&#46;org&#47;gbd-results&#47;</a>&#41;&#46; For a more in-depth understanding of the GBD methodology&#44; readers are referred to the relevant published materials&#46;<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">14&#44;19</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Population data</span><p id="par0045" class="elsevierStylePara elsevierViewall">Age-&#44; sex-&#44; and year-disaggregated population health data for Spain &#40;1990&#8211;2019&#41; were obtained from the Spanish National Statistics Institute &#40;INE&#41; &#40;available online&#58; <a href="https://www.ine.es/en/">https&#58;&#47;&#47;www&#46;ine&#46;es&#47;en&#47;</a>&#41;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Statistical analysis</span><p id="par0050" class="elsevierStylePara elsevierViewall">Joinpoint software &#40;version 4&#46;9&#46;1&#46;0&#41; was used to estimate rates and identify significant changes &#40;turning points&#41; in trends throughout time &#40;available online&#58; <a href="https://surveillance.cancer.gov/joinpoint/">https&#58;&#47;&#47;surveillance&#46;cancer&#46;gov&#47;joinpoint&#47;</a>&#41;&#46; The software default settings were used to calculate the annual percent change &#40;APC&#41; for each identified period&#46; We also obtained the average annual percent change &#40;AAPC&#41; from 1990 through 2019&#44; representing a weighted average of individual APCs&#46; Trend parallelisms between sexes were assessed using the &#8220;pairwise comparison&#8221; option&#46; All rates are presented per 100&#44;000 persons&#46; The male-to-female ratio was also estimated&#46; We used statistically significant changes &#40;<span class="elsevierStyleItalic">p</span>-value<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; to describe trends &#40;e&#46;g&#46;&#44; increase&#44; decrease&#41;&#46; Non-significant trends were described as &#8220;stable&#8221; or &#8220;no change&#46;&#8221;</p><p id="par0055" class="elsevierStylePara elsevierViewall">A-P-C effects were assessed using the National Cancer Institute A-P-C tools &#40;available online&#58; <a href="https://analysistools.nci.nih.gov/apc/">https&#58;&#47;&#47;analysistools&#46;nci&#46;nih&#46;gov&#47;apc&#47;</a>&#41;&#46; We focused on estimable functions&#44; including longitudinal age-specific rates&#44; period and cohort rate ratios&#44; and local drifts with net drift&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The longitudinal age curve provided fitted longitudinal age-specific rates in reference cohorts adjusted for period deviations&#44; while the period &#40;or cohort&#41; relative risk &#40;RR&#41; was adjusted for age and non-linear cohort &#40;or period&#41; effects in a period &#40;or cohort&#41; relative to the reference&#46; Net drift represented the overall log-linear trend by calendar period and birth cohort&#44; indicating the overall annual percent change&#46; Conversely&#44; local drifts reflected the log-linear trend by calendar period and birth cohort for each age group&#44; providing the annual percent change for each age group&#46; All APC analyses used the central age&#44; calendar period and birth cohort as the reference group&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Results</span><p id="par0065" class="elsevierStylePara elsevierViewall">An estimated 2&#46;99 million psoriasis cases were diagnosed in Spain from 1990 through 2019&#46; The mean annual increase was minimal &#40;0&#46;49&#37;&#41;&#44; with a slightly higher increase in men &#40;0&#46;53&#37;&#41; vs women &#40;0&#46;44&#37;&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> shows a significant &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; decrease in the ASIR of psoriasis for both sexes over the study period&#44; with a mean annual decrease of &#8722;0&#46;3&#37;&#46; The ASIR for men dropped from 233&#46;2 down to 212&#46;6 per 100&#44;000 and the ASIR for women from 243&#46;6 down to 222&#46;2&#46; Despite the decline&#44; women consistently maintained a slightly higher ASIR &#40;male&#47;female ratio&#58; 0&#46;95&#41;&#46; Joinpoint analysis revealed five turning points in the downward trend&#44; dividing the period into six segments with different rates of decline&#46; In particular&#44; the decline stabilised in certain periods for both sexes &#40;men&#58; 2008&#8211;2014&#59; women&#58; 1997&#8211;2001 &#38; 2008&#8211;2013&#41;&#46; Interestingly&#44; the most recent period &#40;2017&#8211;2019&#41; showed the sharpest decline for both sexes &#40;&#8722;1&#46;3&#37;&#47;year for men&#44; &#8722;1&#46;5&#37;&#47;year for women&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a> shows the change in the psoriasis incidence rates in Spain from 1990 through 2019&#44; examining both the overall trend &#40;net drift&#41; and the variation between different age groups &#40;local drift&#41;&#46; The overall net drift&#44; representing the mean annual percent change in age-adjusted rates&#44; showed a statistically significant decline for both men &#40;&#8722;0&#46;2&#37; with 95&#37; CI&#58; &#8722;0&#46;22&#37; to &#8722;0&#46;18&#37;&#41; and women &#40;&#8722;0&#46;19&#37; with 95&#37; CI&#58; &#8722;0&#46;21&#37; to &#8722;0&#46;17&#37;&#41;&#46; Local drift refers to age-specific changes in incidence rates over time&#46; Notably&#44; a consistent downward trend was observed in most age groups for both genders&#44; suggesting a broad decrease in the incidence of psoriasis across the population&#46; However&#44; an exception was found in the 25&#8211;34 age group for men&#44; in whom local drift did not exhibit a statistically significant decline&#46; Interestingly&#44; the most substantial declines in local drift were observed in younger age groups&#46; Among men&#44; local drift went from 0&#37; in the 30&#8211;34 age group up to &#8722;0&#46;37&#37; in the 10&#8211;14 age group&#46; Women exhibited the steepest decline in the 5&#8211;14 age group&#44; with local variations ranging from &#8722;0&#46;05&#37; in the 25&#8211;34 age group up to &#8722;0&#46;33&#37; in the 10&#8211;14 age group&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a> shows longitudinal age curves&#44; estimated cohort relative risk &#40;RR&#41; trends&#44; and estimated period RR trends&#46; Longitudinal trends showed a slightly increased risk in women in certain age groups &#40;&#60;25 years and 45&#8211;69 years&#41;&#46; The risk of psoriasis increased steadily with age in both sexes&#44; peaking in the 50&#8211;54 age group and decreasing in the 80&#8211;84 age group&#46; In Spain&#44; a continuous decrease in the risk of psoriasis was observed from 1990 through 2019&#44; affecting both men and women&#46; People born at the beginning of the 21st century had a significantly lower risk vs those born at the beginning of the 20th century&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">Wald tests for both sexes showed statistical significance for all net drifts&#44; local drifts&#44; cohort effects and period effects &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; These results highlight a significant difference in the incidence of psoriasis concerning local and net drifts&#44; as well as age&#44; period and cohort effects&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Discussion</span><p id="par0090" class="elsevierStylePara elsevierViewall">Our study is consistent with overall observations of a slight decline in the reported incidence of psoriasis&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">20</span></a> However&#44; interpreting these trends can be challenging&#46; Increased awareness among health care professionals and the public&#44; along with improved diagnostic tools&#44; could lead to more diagnosed cases&#44; even if the actual prevalence remains stable&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">7&#44;14&#44;21</span></a> The influence of socioeconomic factors on access to health care can also impact the observed trends in the incidence of psoriasis&#46;<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">22&#44;23</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Our study found a slightly higher incidence of psoriasis in women vs men&#44; yet the difference was minimal &#40;male-to-female ratio of 0&#46;95&#41;&#46; This is consistent with other researches that report similar rates between sexes&#46;<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">8&#44;20&#44;24&#44;25</span></a> Worldwide&#44; the incidence of psoriasis seems similar in women and men &#40;1&#46;00 ratio for 1990&#8211;2019&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">20</span></a> While some studies show variations in incidence and severity by sex&#44;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">7&#44;18</span></a> these variations are often small&#44; and their clinical significance remains unclear&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Some studies&#44;<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">14&#44;16</span></a> including one conducted with the population of Lleida&#44; Spain&#44;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">26</span></a> highlight a peak incidence of psoriasis that usually occurs in the 50&#8211;54 age group&#44; followed by a decline later in life&#44; reflecting our observations for Spain as a whole&#46; Conversely&#44; other areas show a bimodal distribution&#44; characterized by two distinct incidence peaks in different age groups&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">7&#44;8&#44;27</span></a> The first peak tends to manifest itself in early adulthood&#44; between the ages of 30 and 39&#44; followed by a decline before a resurgence in later years&#44; typically around 60&#8211;69 years of age&#46; This is entirely consistent with the accepted classification of chronic plaque psoriasis as &#8216;type I&#8217; &#40;early onset&#41; and &#8216;type II&#8217; &#40;late onset&#41;&#44; which is defined as occurring at &#8804;40 and &#62;40 years of age&#44; respectively&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">28</span></a> Our findings and existing research<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">8</span></a> suggest a higher prevalence of early-onset psoriasis in women&#44; peaking in their late teens and early twenties&#44; vs men who experience a later peak in their thirties&#46; Hormonal fluctuations during puberty and perimenopause are thought to be contributing factors to this difference&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">29</span></a> Furthermore&#44; exposure to certain environmental triggers&#44; such as specific drugs or endocrine-disrupting chemicals found in some cosmetics&#44; could contribute to the observed gender-based differences in the reported incidence rates&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">29</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Notably&#44; a recent Israeli study reported an earlier onset&#44; with the first peak being observed even earlier&#44; at 25&#8211;34 years of age&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">9</span></a> These findings highlight the importance of considering age-related variations in the onset of psoriasis&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">30</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Our study revealed a significant decline in the incidence of psoriasis among younger age groups &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Interestingly&#44; the overall burden of psoriasis in young adults also decreased worldwide during this period&#44; but at varying rates&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">21</span></a> Notably&#44; North Africa&#44; the Middle East&#44; Western sub-Saharan Africa&#44; and East Asia witnessed the most rapid decline&#44; whereas regions like Tropical Latin America&#44; Western Europe&#44; and the high-income Asia Pacific regions showed the slowest decrease&#46; The latter observation might be partially explained by the rising prevalence of obesity &#8211; a known risk factor for psoriasis &#8211; in these areas&#46; Furthermore&#44; countries such as Japan&#44; Sweden&#44; and Somalia exhibited the most significant changes in the age-adjusted incidence rates of psoriasis among young people&#46; This could potentially be associated with factors such as economic development&#44; advancements in medical technology&#44; and improved preventative measures and treatments for psoriasis implemented in these countries during the study period&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">When considering factors influencing trends over time &#40;period effect&#41; and across different birth years &#40;cohort effect&#41;&#44; our findings show a decrease in relative risks similar to what has been observed in other countries&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">16</span></a> This decline suggests a potential reduction in exposure to risk factors or triggers over the observed period&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">While genetics plays a significant role in psoriasis susceptibility&#44; environmental factors act as triggers&#44; initiating the disease process&#46;<a class="elsevierStyleCrossRefs" href="#bib0365"><span class="elsevierStyleSup">31&#44;32</span></a> Well-established triggers include stress&#44; infections&#44; and specific drugs&#46; Beyond these&#44; several factors contribute to the onset and severity of psoriasis&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Both genetic and environmental factors influence psoriasis development and progression&#46; Genetic risks involve variations in genes such as the HLA-Cw6 and CARD14&#46; Environmental factors include infectious diseases &#40;particularly streptococcal pharyngitis&#44; which can trigger flare-ups&#41;&#44; use of medication &#40;beta-blockers and lithium&#44; have been associated with the development or worsening of psoriasis&#41;&#44; and lifestyle choices &#40;obesity&#44;<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">33&#44;34</span></a> smoking<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">35</span></a> and alcohol<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">36</span></a> contribute to the risk and severity of psoriasis&#41;&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">It is well known that smoking influences the onset of the disease as well as its progression&#46;<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">37</span></a> Smoking habits in Spain have changed in recent years&#44; with a decrease in the number of smokers&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">38</span></a> This decline is consistent with the decrease in the incidence rate of psoriasis in our findings&#46; While a cause-and-effect relationship cannot be definitively established from this data alone&#44; research suggests that smoking can worsen psoriasis and increase the risk of health-related problems&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">35</span></a> This highlights the potential benefits of smoking cessation for both managing psoriasis and reducing the risk of associated comorbidities&#46; Raising awareness of psoriasis risk factors through health education can empower young adults to adopt healthier habits&#44; potentially reducing their risk of developing the condition&#46;<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">21&#44;39</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Obesity is a well-established risk factor for psoriasis&#44; and its rising prevalence could hinder efforts to decrease the burden of psoriasis&#44; especially in certain regions&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">10</span></a> Studies in Spain have shown a higher prevalence of obesity among individuals with psoriasis&#44;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">40</span></a> and a confirmed association between metabolic syndrome &#40;a cluster of conditions often linked to obesity&#41; and psoriasis has been established&#46;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">41</span></a> The obesity rates reported in Spain have continuously increased since 1987&#44; remaining &#62;15&#37; in recent years&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">42</span></a> This concerning trend is consistent with the observed rise in psoriasis cases&#44; suggesting that increasing obesity rates in Spain might be a contributing factor&#44; similar to what has been reported in other countries&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">4&#44;10</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Public education and awareness campaigns are essential to improve our understanding of psoriasis&#44; including triggers and management strategies&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">31</span></a> This empowers individuals to take steps to avoid triggers&#44; such as skin damage and certain drug use and maintain a healthy lifestyle&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">While our study used robust A-P-C analysis and the comprehensive GBD database to investigate psoriasis trends in Spain&#44; the GBD data <span class="elsevierStyleItalic">per se</span> has limitations to be able to establish definitive causal relationships between observed trends and potential influencing factors&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">14</span></a> These data&#44; compiled from a variety of sources including research and government reports&#44; vary in quality and completeness across regions&#44; which may affect the accuracy of estimates14&#46; The reliance on reported diagnoses introduces bias influenced by differences in access to health care and coding practices over time&#46; The GBD reliance on modelled data&#44; compounded by variations in the quality of raw data may affect the reliability of the results&#46; In particular&#44; the GBD datasets do not distinguish between early- and late-onset psoriasis&#44; which limits the scope of our analysis&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">In addition to these GBD-related limitations&#44; our ecological study design &#8211; which analyses data at population level &#8211; raises the possibility of ecological bias&#46; This means that population-level associations may not reflect the true cause&#8211;effect relationships at individual level&#46; Changes in diagnostic practices&#44; access to health care&#44; or public health policies could also influence the observed trends&#46; For example&#44; stricter diagnostic criteria or limited access to dermatologists could lead to an apparent decrease in the reported incidence rates even if true prevalence remains stable&#46; Conversely&#44; increased awareness or shorter waiting times could lead to a perceived increase&#46; We were not able to adjust for these potential confounders in this study&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">More research is needed to explore the complex interplay between genetic and environmental factors contributing to psoriasis&#46; Studies using data at individual level can examine potential contributing factors in more detail&#44; such as changes in diagnostic coding practices&#44; patterns of health care use and environmental exposures&#46; In addition&#44; future studies should use data sources that differentiate between early- and late-onset psoriasis to gain deeper insights into this important distinction&#46; This comprehensive approach will help elucidate the reasons for the observed decline in the reported incidence rates of psoriasis and inform the development of effective prevention and management strategies&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Further research is needed to explore the complex interplay of genetic and environmental factors and to establish definitive causal relationships between observed trends and potential influencing factors&#46; Additionally&#44; future studies should consider utilizing data sources that differentiate between early- and late-onset psoriasis to gain deeper insights into this important distinction&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Our study observed a slight decline in reported psoriasis ASIR in Spain&#44; which is consistent with global trends&#46; This decline might be due to reduced exposure to risk factors over time&#46; However&#44; interpreting these trends is complex due to potential biases and limitations in the data used&#46; Further research is needed to explore the underlying mechanisms behind these observations and gain a deeper understanding of the factors influencing the incidence of psoriasis in Spain&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Ethical approval</span><p id="par0170" class="elsevierStylePara elsevierViewall">This study employed anonymized data from the Global Burden of Disease &#40;GBD&#41; study&#44; adhering to the principles of good clinical practice &#40;GCP&#41; and the Declaration of Helsinki&#46; As the data were anonymized and no personal information was accessed&#44; informed consent from participants or approval from an ethics committee was not required&#46; Additionally&#44; adherence to the Guidelines for Accurate and Transparent Health Estimation Reporting for Population Health Research &#40;GATHER&#41; safeguards the credibility and integrity of the findings&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Funding</span><p id="par0175" class="elsevierStylePara elsevierViewall">This research did not receive any specific grants from funding agencies in the public&#44; commercial or nonprofit sectors&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Authors&#8217; contributions</span><p id="par0180" class="elsevierStylePara elsevierViewall">All authors contributed to the conception and design of the work&#59; the acquisition&#44; analysis&#44; and interpretation of data&#59; drafting the work and revising it critically for important intellectual content&#59; approved the version to be published&#59; and are responsible for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are properly investigated and resolved&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Conflict of interest</span><p id="par0185" class="elsevierStylePara elsevierViewall">The authors did not declare conflicts of interest in relation to the contents of this manuscript&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Data availability</span><p id="par0190" class="elsevierStylePara elsevierViewall">The data that support the findings of this study are openly available at&#58; <a href="https://vizhub.healthdata.org/gbd-results/">https&#58;&#47;&#47;vizhub&#46;healthdata&#46;org&#47;gbd-results&#47;</a> and <a href="https://www.ine.es/en/">https&#58;&#47;&#47;www&#46;ine&#46;es&#47;en&#47;</a>&#46;</p></span></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Aim</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">This study aimed to investigate the effects of age&#44; period&#44; and cohort on the incidence of psoriasis in Spain from 1990 through 2019 using the Global Burden of Disease &#40;GBD&#41; database and age-period-cohort &#40;A-P-C&#41; analysis&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">We conducted an ecological trend study to analyze the incidence rates of psoriasis in Spain from 1990 through 2019&#46; Joinpoint Regression Program&#44; Version 5&#46;0&#46;2 - May 2023&#59; Surveillance Research Program&#44; National Cancer Institute and National Cancer Institute A-P-C tools were used to identify trends and assess the effects of age&#44; period&#44; and cohort&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">From 1990 through 2019&#44; an estimated 2&#46;99 million cases of psoriasis were diagnosed in Spain&#44; with a mean annual increase of 0&#46;49&#37;&#46; Significant decreases in age-standardized incidence rates &#40;ASIR&#41; were reported for both sexes&#44; with women consistently maintaining a slightly higher ASIR&#46; Joinpoint analysis revealed multiple turning points in the downward trend&#44; indicating periods of stabilization&#46; A-P-C analysis demonstrated significant declines in both net &#40;overall trend&#41; and local drift &#40;age-specific trends&#41;&#44; indicating a broad decrease in the incidence of psoriasis across most age groups&#46; While the risk of psoriasis increased with age&#44; peaking in the 50&#8211;54 age group&#44; it declined thereafter&#46; Furthermore&#44; the analysis revealed a continuous decline in risk from 1990 through 2019 for both sexes&#44; with individuals born in the early 21st century exhibiting a significantly lower risk vs those born in the early 20th century&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusion</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">This study observed a slight decline in the reported psoriasis ASIR in Spain&#44; potentially due to reduced exposure to risk factors&#46; However&#44; limitations in data and the complexity of factors influencing the incidence of psoriasis require further research&#46;</p></span>"
        "secciones" => array:4 [
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        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Objetivo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Este estudio tuvo como objetivo investigar los efectos de la edad&#44; el periodo y la cohorte de nacimiento en la incidencia de psoriasis en Espa&#241;a entre 1990 y 2019&#44; utilizando la base de datos <span class="elsevierStyleItalic">Global Burden of Disease</span> &#40;GBD&#41; y un an&#225;lisis de edad-periodo-cohorte &#40;A-P-C&#41;&#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 llev&#243; a cabo un estudio de tendencia ecol&#243;gica&#44; analizando las tasas estandarizadas de incidencia de psoriasis en Espa&#241;a de 1990 a 2019&#46; Se utilizaron el <span class="elsevierStyleItalic">software</span> Joinpoint Regression&#44; Versi&#243;n 5&#46;0&#46;2 - Mayo 2023&#59; Surveillance Research Program&#44; National Cancer Institute y las herramientas A-P-C del Instituto Nacional del C&#225;ncer para identificar tendencias y evaluar los efectos de edad&#44; periodo y cohorte&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Resultados</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Entre 1990 y 2019 se diagnosticaron aproximadamente 2&#44;99 millones de casos de psoriasis en Espa&#241;a&#44; con un aumento anual promedio del 0&#44;49&#37;&#46; Se observaron disminuciones significativas en las tasas de incidencia estandarizadas por edad &#40;ASIR&#41; para ambos sexos&#44; manteniendo las mujeres consistentemente una ASIR ligeramente m&#225;s alta&#46; El an&#225;lisis de Joinpoint revel&#243; m&#250;ltiples puntos de inflexi&#243;n en la tendencia descendente&#44; indicando periodos de estabilizaci&#243;n&#46; El an&#225;lisis A-P-C demostr&#243; disminuciones significativas tanto en tendencia general como en las tendencias espec&#237;ficas por edad&#44; lo que indica una disminuci&#243;n general en la incidencia de psoriasis en la mayor&#237;a de los grupos de edad&#46; Mientras que el riesgo de psoriasis aument&#243; con la edad&#44; alcanzando su punto m&#225;ximo en el grupo de edad de 50-54 a&#241;os&#44; disminuy&#243; despu&#233;s&#46; Adem&#225;s&#44; el an&#225;lisis revel&#243; una disminuci&#243;n continua en el riesgo desde 1990 hasta 2019 para ambos sexos&#44; con las personas nacidas a principios del siglo <span class="elsevierStyleSmallCaps">XXI</span> mostrando un riesgo significativamente menor en comparaci&#243;n con aquellas nacidas a principios del siglo <span class="elsevierStyleSmallCaps">XX</span>&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conclusi&#243;n</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">El presente estudio observ&#243; una ligera disminuci&#243;n en la ASIR de psoriasis reportada en Espa&#241;a&#44; posiblemente debido a una reducci&#243;n en la exposici&#243;n a factores de riesgo&#46; Sin embargo&#44; las limitaciones en los datos y la complejidad de los factores que influyen en la incidencia de la psoriasis requieren m&#225;s investigaciones&#46;</p></span>"
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