To the Editor:
Few US-based studies on psoriasis and psoriatic arthritis (PsA) have focused on recruiting underrepresented demographic and socioeconomic groups. We conducted a cross-sectional study to estimate the burden of psoriasis and PsA across underrepresented groups utilizing the All of Us Research Program, an ongoing prospective study of US adults.1,2
After we linked data from electronic health records (EHRs), surveys, and physical measurements, we estimated the prevalence of psoriasis and PsA by demographic and socioeconomic factors among those with EHRs, as psoriasis diagnosis may not be available among those without EHR. Odds ratios and 95% confidence intervals were estimated with age-adjusted and multivariate logistic regression (Supplemental Methods).
The demographic distribution of study participants is summarized in Table I. Of participants with EHR, 6,367 (2.6%) were diagnosed with psoriasis. Nearly a quarter (n=1,364; 21.4%) of them also had PsA. Lower odds of psoriasis were observed among those with a high school (HS) degree and less than a HS degree compared to college graduates (Table II). Lower odds of psoriasis were observed among uninsured compared to insured. Odds of psoriasis were lower among Blacks and Hispanics compared to Whites. There was no difference in psoriasis prevalence by gender or income. The results regarding race/ethnicity and education remained robust in an analysis excluding uninsured (Supplemental Table I).
Table I.
Demographic distribution for participants with psoriasis and psoriatic arthritis in the All of Us Research Program
| Enrolled | EHR Data Available | No Psoriasis | Psoriasis | Psoriatic Arthritis | |
|---|---|---|---|---|---|
|
| |||||
| n (%) | n (%) | n (%) | n (%) | n (%) | |
| Race/ethnicity | |||||
| White | 193,052 (52) | 124,892 (52) | 120,416 (51) | 4,476 (70) | 992 (73) |
| Asian | 12,085 (3) | 6,290 (3) | 6,156 (3) | 134 (2) | 23 (2) |
| Black | 71,897 (19) | 48,717 (20) | 48,249 (21) | 468 (7) | 72 (5) |
| Hispanic | 66,530 (18) | 44,720 (19) | 43,883 (19) | 837 (13) | 176 (13) |
| Othera | 12,298 (3) | 7,647 (3) | 7,454 (3) | 193 (3) | 47 (3) |
| Age (years) b | |||||
| 18–29 | 51,604 (14) | 29,815 (12) | 29,520 (13) | 295 (5) | 40 (3) |
| 30–39 | 58,124 (16) | 35,884 (15) | 35,272 (15) | 612 (10) | 109 (8) |
| 40–49 | 55,114 (15) | 34,996 (15) | 34,259 (15) | 737 (12) | 182 (13) |
| 50–59 | 73,770 (20) | 49,170 (20) | 47,860 (20) | 1,310 (21) | 334 (24) |
| 60–69 | 75,511 (20) | 51,759 (22) | 49,944 (21) | 1,815 (29) | 410 (30) |
| 70+ | 55,155 (15) | 39,010 (16) | 37,412 (16) | 1,598 (25) | 289 (21) |
| Gender | |||||
| Female | 219,020 (59) | 144,742 (60) | 141,009 (60) | 3,733 (59) | 848 (62) |
| Male | 136,102 (37) | 87,442 (36) | 85,046 (36) | 2,396 (38) | 470 (34) |
| Other | 14,156 (4) | 8,450 (4) | 8,212 (4) | 238 (4) | 46 (3) |
| Education | |||||
| Completed College | 157,595 (43) | 98,234 (41) | 95,051 (41) | 3,183 (50) | 663 (49) |
| Completed High School | 162,656 (44) | 109,526 (46) | 106,907 (46) | 2,619 (41) | 594 (44) |
| Less than High School Degree | 34,056 (9) | 23,610 (10) | 23,256 (10) | 354 (6) | 67 (5) |
| Annual Household Income ($) | |||||
| >35,000 | 213,695 (58) | 135,703 (56) | 131,484 (56) | 4,219 (66) | 918 (67) |
| ≤35,000 | 78,844 (21) | 52,279 (22) | 51,263 (22) | 1,016 (16) | 210 (15) |
| N/A | 76,739 (21) | 52,652 (22) | 51,520 (22) | 1,132 (18) | 236 (17) |
| Smoking Status | |||||
| Current | 207,192 (56) | 137,163 (57) | 133,908 (57) | 3,255 (51) | 686 (50) |
| Former | 61,180 (17) | 41,084 (17) | 40,304 (17) | 780 (12) | 155 (11) |
| Never | 79,677 (22) | 55,290 (23) | 53,120 (23) | 2,170 (34) | 498 (37) |
| BMI (kg/m 2 ) | |||||
| <18.5 | 4,390 (1) | 3,232 (1) | 3,165 (1) | 67 (1) | 14 (1) |
| 18.5–24.9 | 79,088 (21) | 59,673 (25) | 58,392 (25) | 1,281 (20) | 247 (18) |
| 25–29.9 | 90,259 (24) | 70,101 (29) | 68,254 (29) | 1,847 (29) | 367 (27) |
| 30–34.9 | 60,664 (16) | 48,141 (20) | 46,748 (20) | 1,393 (22) | 288 (21) |
| 35–39.9 | 34,155 (9) | 27,360 (11) | 26,497 (11) | 863 (14) | 223 (16) |
| 40+ | 28,116 (8) | 22,978 (10) | 22,283 (10) | 695 (11) | 169 (12) |
| Insurance Status | |||||
| Yes | 327,898 (89) | 216,146 (90) | 210,106 (90) | 6,040 (95) | 1,291 (95) |
| No | 24,863 (7) | 14,655 (6) | 14,542 (6) | 113 (2) | 23 (2) |
Abbreviations: BMI, body mass index; EHR, electronic health record; N/A, not applicable.
This category consists of the following groups: participants who selected ‘More than one population’, ‘Another single population’, or ‘None of these.’
Age refers to age at consent.
Subgroup sums may not equal each other due to missing values.
Table II.
Odds ratios (ORs) of prevalence of psoriasis and psoriatic arthritis in the All of Us Research Program
| Psoriasis | Psoriatic Arthritis | |||
|---|---|---|---|---|
|
| ||||
| Age-Adjusted | Multivariate | Age-Adjusted | Multivariate | |
|
| ||||
| OR (95% CI) | OR (95% CI) | OR (95% CI) | OR (95% CI) | |
| Race/ethnicity | ||||
| White | Reference | Reference | Reference | Reference |
| Asian | 0.74 (0.61–0.87) | 0.84 (0.70–1.00) | 0.57 (0.36–0.84) | 0.73 (0.47–1.08) |
| Black | 0.29 (0.27–0.32) | 0.31 (0.28–0.35) | 0.20 (0.16–0.25) | 0.20 (0.16–0.26) |
| Hispanic | 0.63 (0.59–0.69) | 0.73 (0.67–0.79) | 0.60 (0.51–0.71) | 0.70 (0.59–0.84) |
| Age (years) a | ||||
| 18–29 | Reference | Reference | Reference | Reference |
| 30–39 | 1.74 (1.51–2.00) | 1.54 (1.33–1.78) | 2.25 (1.58–3.27) | 2.06 (1.43–3.02) |
| 40–49 | 2.15 (1.88–2.47) | 1.96 (1.70–2.25) | 3.87 (2.78–5.53) | 3.56 (2.53–5.15) |
| 50–59 | 2.74 (2.42–3.12) | 2.51 (2.20–2.86) | 5.08 (3.70–7.15) | 4.71 (3.40–6.73) |
| 60–69 | 3.64 (3.22–4.12) | 2.95 (2.59–3.36) | 5.93 (4.34–8.33) | 4.75 (3.43–6.77) |
| 70+ | 4.27 (3.78–4.85) | 3.00 (2.64–3.43) | 5.52 (4.01–7.80) | 3.82 (2.73–5.50) |
| Gender | ||||
| Male | Reference | Reference | Reference | Reference |
| Female | 1.02 (0.97–1.08) | 1.00 (0.95–1.06) | 1.19 (1.06–1.33) | 1.13 (1.01–1.28) |
| Other | 1.09 (0.95–1.24) | 1.14 (0.95–1.36) | 1.05 (0.76–1.41) | 1.03 (0.66–1.54) |
| Education | ||||
| College graduate or advanced degree | Reference | Reference | Reference | Reference |
| High school degree | 0.80 (0.76–0.85) | 0.90 (0.84–0.95) | 0.88 (0.79–0.98) | 0.97 (0.86–1.10) |
| Less than a high school degree or equivalent | 0.50 (0.45–0.56) | 0.71 (0.62–0.80) | 0.46 (0.35–0.58) | 0.66 (0.49–0.87) |
| Annual Household Income ($) | ||||
| >35,000 | Reference | Reference | Reference | Reference |
| ≤35,000 | 0.71 (0.66–0.76) | 0.95 (0.88–1.03) | 0.67 (0.58–0.78) | 0.94 (0.80–1.11) |
| Smoking Status | ||||
| Never | Reference | Reference | Reference | Reference |
| Current | 0.84 (0.78–0.91) | 1.12 (1.03–1.22) | 2.08 (1.42–3.19) | 1.66 (1.10–2.62) |
| Former | 1.38 (1.30–1.46) | 1.31 (1.23–1.38) | 1.10 (0.74–1.72) | 1.18 (0.79–1.87) |
| BMI (kg/m 2 ) | ||||
| <18.5 | 1.04 (0.81–1.33) | 1.14 (0.88–1.46) | 1.13 (0.63–1.86) | 1.26 (0.70–2.09) |
| 18.5–24.9 | Reference | Reference | Reference | Reference |
| 25–29.9 | 1.13 (1.05–1.21) | 1.15 (1.07–1.24) | 1.15 (0.98–1.36) | 1.18 (1.00–1.39) |
| 30–34.9 | 1.25 (1.16–1.36) | 1.33 (1.23–1.44) | 1.34 (1.13–1.59) | 1.39 (1.17–1.66) |
| 35–39.9 | 1.45 (1.33–1.58) | 1.57 (1.44–1.72) | 1.91 (1.59–2.29) | 1.97 (1.64–2.37) |
| 40+ | 1.51 (1.37–1.65) | 1.71 (1.55–1.88) | 1.86 (1.53–2.26) | 1.97 (1.61–2.41) |
| Insurance Status | ||||
| Health Insurance: Yes | Reference | Reference | Reference | Reference |
| Health Insurance: No | 0.33 (0.27–0.40) | 0.46 (0.37–0.55) | 0.32 (0.21–0.47) | 0.46 (0.30–0.69) |
Abbreviations: BMI, body mass index.
Age refers to age at consent.
Lower odds of PsA were observed among those with less than a HS degree compared to those with a college degree. Lower odds were also observed among uninsured compared to insured. Analysis excluding uninsured similarly found lower rates of PsA among individuals with lower educational attainment (Supplemental Table I).
The prevalence of psoriasis and PsA among individuals with psoriasis in our study are similar to the psoriasis prevalence of 3.0% based on the National Health and Nutrition Examination Survey and PsA rate of 19.7% in a meta-analysis with European, Asian, American, and African studies.3,4 Lower rates of psoriasis have been reported in Blacks and Hispanics, which is consistent with our study.3 We found differences in psoriasis and PsA rates based on education and insurance status.3 These results may differ due to the higher proportion of underrepresented groups in our study. Our sensitivity analysis demonstrated that lack of insurance may not account for the differences in prevalence in people of color (POC) and education.
This study benefits from outcome data based on EHRs. Limitations include unavailability of psoriasis severity and diagnosis age data. Participants are not a random sample of the US population. While All of Us focuses on recruiting underrepresented groups, it is currently not as diverse as the US population. EHR data may be fragmented from algorithmic processing, potentially leading to missing diagnoses, and EHR completeness data was unavailable.
Our findings suggest potential underdiagnosed psoriasis and PsA among those without health insurance and with lower levels of education. Future research on access to specialty care, diagnostic bias, and genetic risk factors is warranted to discern the extent to which these contribute to rates of psoriasis and PsA in POC, less educated, and uninsured groups.
Supplementary Material
Acknowledgements
The All of Us Research Program is supported by the National Institutes of Health, Office of the Director: Regional Medical Centers: 1 OT2 OD026549; 1 OT2 OD026554; 1 OT2 OD026557; 1 OT2 OD026556; 1 OT2 OD026550; 1 OT2 OD 026552; 1 OT2 OD026553; 1 OT2 OD026548; 1 OT2 OD026551; 1 OT2 OD026555; IAA #: AOD 16037; Federally Qualified Health Centers: HHSN 263201600085U; Data and Research Center: 5 U2C OD023196; Biobank: 1 U24 OD023121; The Participant Center: U24 OD023176; Participant Technology Systems Center: 1 U24 OD023163; Communications and Engagement: 3 OT2 OD023205; 3 OT2 OD023206; and Community Partners: 1 OT2 OD025277; 3 OT2 OD025315; 1 OT2 OD025337; 1 OT2 OD025276. In addition, the All of Us Research Program would not be possible without the partnership of its participants.
Funding sources:
This article has no funding source.
Footnotes
Conflicts of Interest: The authors have no conflict of interest to declare.
Patient consent: Not applicable.
IRB approval status: The National Institute of Health All of Us Institutional Review Board approved All of Us protocol and materials.
Prior presentation: Preliminary analysis was presented at the Society for Investigative Dermatology meeting at Portland, Oregon in 2022.
Supplement Materials hosted at: https://data.mendeley.com/datasets/9p2tswhnhz/1
References
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