doi: 10.1111/1346-8138.

14321 Journal of Dermatology 2018; : 1–4

ORIGINAL ARTICLE
Relationship between environmental factors, age of onset
and familial history in Japanese patients with psoriasis
Bolortuya BAYARAA, Shinichi IMAFUKU
Department of Dermatology, Fukuoka University Faculty of Medicine, Fukuoka, Japan

ABSTRACT
Psoriasis is a chronic inflammatory disease that often involves the skin and joints. Psoriasis develops at any age
and the distribution of age of onset of psoriasis is bimodal in Japan. Also, male predominance is distinct in Japa-
nese psoriatic patients. To clarify the relationship between sex difference and habitual/environmental status, age
and incidence of familial psoriasis, we analyzed data from the Fukuoka University Psoriasis Registry. A total of
1120 Japanese patients (751 men, 369 women) were analyzed. The male/female ratio was 2.03:1. Smoking and
drinking habit, known as risk factors of psoriasis, were significantly more prevalent in men. Age-specific psoria-
sis-onset rate standardized by population showed bimodal distribution in both men and women; the younger peak
was in their 30s for men and 10s in women; the second peak was in the 50s for both sexes. A familial history of
psoriasis was seen in 6.3% of patients overall; however, female patients showed a significantly higher rate (8.7%)
compared with men (5.1%, P = 0.024). When stratified by age of onset, the frequency of familial history was much
higher among women with onset at less than 30 years (15.4%), compared with 30 years or more (5.3%,
P = 0.0026). Our data suggest that genetic factors have a stronger influence in young women who experience
fewer environmental factors such as smoking and drinking. This is the first study to show that there is a differ-
ence in the incidence of familial psoriasis depending on age of onset of psoriasis in Japan.

Key words: psoriasis, age of onset, Japan, male/female ratio, familial psoriasis.

INTRODUCTION METHODS
Patients
Psoriasis is a chronic inflammatory skin disease that affects
Among patients who visited the Department of Dermatology,
approximately 0.34–0.44% of the Japanese population.1 Both
Fukuoka University Hospital from 1998 to December 2016, those
a genetically-conferred inflammatory predisposition and envi-
diagnosed as having psoriasis are registered in the FUPR. Clini-
ronmental factors cause the disease. In addition, sex may
cal information was extracted from these patient registration
also be greatly involved in the pathogenesis of psoriasis
data. Patients were investigated. The following information was
because there are more male patients in most of the racial
extracted: sex, initial age of presentation, age of onset, height,
groups.
bodyweight, BMI at the first visit, drinking habit (once a month or
In the Fukuoka University Hospital Department of Dermatol-
more), smoking habit (current or past smoking), and the pres-
ogy, all patients diagnosed as having psoriasis who have vis-
ence or absence of psoriatic arthritis, nail symptoms, itching, a
ited since 1998 are registered (Fukuoka University Psoriasis
familial history of psoriasis and comorbidities (diabetes, hyper-
Registry, FUPR). From this cohort, we have reported that the
tension, obesity, myocardial infarction, cerebrovascular acci-
body mass index (BMI) of psoriatic patients is higher than that
dent, hepatitis). This study was approved by the internal review
of controls, the distribution of obesity is different between men
board of Fukuoka University Hospital. The study conforms to the
and women,2 the positive rate of hepatitis C is higher than that
principles of the Declaration of Helsinki.
of controls,3 and in patients with arthropathy, hyperuricemia is
more prevalent.4
In this research, we investigated whether sex differences
RESULTS
are affected by other factors such as lifestyle habits, age at Patients background
first visit, age of onset, family history of psoriasis and From 1998 to 2016, 1120 patients with psoriasis were regis-
complications. tered in the FUPR (751 men, 369 women; male/female ratio

Correspondence: Shinichi Imafuku, M.D., Ph.D., Department of Dermatology, Fukuoka University Faculty of Medicine, 7-45-1 Nanakuma,
Fukuoka-shi, Fukuoka 814-0180, Japan. Email: dermatologist@mac.com
Received 21 December 2017; accepted 7 March 2018.

© 2018 Japanese Dermatological Association 1

B. Bayaraa and S. Imafuku

2.03:1). The backgrounds of patients are summarized in
Table 1. Their mean age at their first visit was 51 years (17
standard deviation [SD]) in men, 51 years (19 SD) in women
and 51 years (18 SD) in total. The mean age of onset was
43 years (18 SD) in men, 43 years (21 SD) in women and
43 years (19 SD) for all patients.
Complication and habits
As complications, psoriatic arthritis was seen in 13.0% of men,
10.1% of women and 12.2% in total. Characteristics found sig-
nificantly more often in men than women were nail symptoms
(32.7% vs 22.5%, P < 0.0015), drinking habit (57.8% vs
34.6%, P < 0.0001), smoking habit (65.3% vs 33.6%,
P < 0.0001), and association with diabetes mellitus (18.6% vs
11.1%, P < 0.0087) and hepatitis (including type B, hepatitis C,
reported fatty liver 16% vs 7.6%, P < 0.0001).
Relationship between male/female ratio and age of
onset
The age of onset was analyzed in further detail. Age of onset
of psoriasis ranged 0–99 years. As shown in Figure 1(a), when
the number of the male/female patients was shown in a his-
togram by onset-age bracket, the distribution was bimodal in
both men and women. However, statistical analysis showed
that the two groups had significantly different distribution of
onset age. (v2-test, P < 0.0003). When these numbers were
shown as percentage of total patients by sex, and standard-
ized by mean age-specific Japanese population (1998–2016),
Figure 1(b) was obtained. This histogram shows the highest
value in the 30s (17.6%) in men, and only a slight notch in the
40s followed by second peak in the 50s (14.0%). On the other
hand, women had the highest value in the 10s, which shares
14.3% of total female patients, and a wider large notch
between the next peak of the 50s (13.1%). The greatest differ-
ence between men and women was seen in the 10s and 30s
with a male/female ratio of 0.64 and 1.96, respectively.
Relationship between sex, age of onset and familial
psoriasis
A familial history of psoriasis was seen in 6.3% of patients;
however, female patients showed a higher rate (8.7%) com-
pared with men (5.1%, P < 0.0024; Tables 2,3). The proportion
of female patients with a family history is 1.70-times more than
that for men, and the average age of onset of such patients is
35.2 years for men and 28.0 years for women. When stratified
by age of onset, the frequency of familial history was higher
among women with onset at less than 30 years (15.4%), com-
pared with 30 years and older (5.3%, P < 0.0026). In contrast,
men did not show a difference by onset age (<30 [5.6%] and
≥30 [4.9%], P < 0.7074).
DISCUSSION
In this study, we found that psoriasis is more common in men
than in women with a male/female ratio of 2.03:1. Female
patients had lower rates of drinking and smoking habit than
male patients. The distribution of onset age was statistically
different between men and women, with more onset in their
30s in men while sharp peaks in 10s and 50s were observed
with a large notch between them in women. The incidence of
familial psoriasis was markedly higher in female patients with
early (<30 years) onset (15.4%) than in all other categories,
namely men with either early or late (≥30) onset (5.6% and
4.9%, respectively) and women with late onset (5.3%).

Table 1. Clinical characteristics of patients in the Fukuoka University Psoriasis Registry

Male Female Total P

No. of psoriatic patients 751 (67%) 369 (33%) 1120 (100%)
Age (years) 51  17 51  19 51  18
Onset age 43  18 43  21 43  19
BMI 23.7  4.8 23.1  5.9 23.8  4.2
Psoriatic arthritis 97 (13%) 40 (10.1%) 137 (12.2%) 0.4351
Nail symptom 196 (32.7%) 68 (22.5%) 264 (29.4%) 0.0015**
Itchy 274 (36.5%) 137 (34.6%) 411 (36.7%) 0.0075**
Family history
Psoriasis vulgaris 38 (5.1%) 32 (8.7%) 70 (6.3%) 0.024*
Atopic dermatitis 32 (4.3%) 22 (5.6%) 54 (4.8%) 0.379
Life history
Drinking habit 278 (57.8%) 80 (34.6%) 358 (50.3%) 0.0001**
Smoking habit 335 (65.3%) 83 (33.6%) 418 (55%) 0.0001**
Comorbidities
Diabetes 140 (18.6%) 44 (11.1%) 184 (16.4%) 0.0087**
Hypertension 212 (28.2%) 94 (23.7%) 306 (27.3%) 0.188
Obesity 217 (28.9%) 97 (24.5%) 314 (28%) 0.4735
Myocardial infarction 19 (2.5%) 6 (1.5%) 25 (2.2%) 0.1731
Cerebrovascular disorder 19 (2.5%) 5 (1.3%) 24 (2.1%) 0.3687
Hepatitis 120 (16%) 30 (7.6%) 150 (13.4%) 0.0001**

Statistically significant differences between sexes are shown as *(P < 0.05) and **(P < 0.01). BMI, body mass index.

2 © 2018 Japanese Dermatological Association

 Psoriasis onset age and M/F ratio in Japan

In all previous Japanese studies, more male patients were

Figure 1. Histograms of psoriatic patients in Fukuoka Univer-
sity Psoriasis Registry. (a) Number of psoriatic patients strati-
fied by age bracket. The number of patients with onset of less
than 20 years old were almost the same in men and women,
while a marked difference was seen after their 20s. The differ-
ence becomes smaller (male/female ratio <2.0) in the patients’
50s. (b) Onset age-specific rate of psoriasis in men and
women. The proportion of patients at each onset-age bracket
was adjusted by mean Japanese population age from 1998 to
2016.
found.5,6 Psoriasis develops in response to genetic predisposi-
tion as well as environmental/habitual factors. Drinking alcohol
and smoking are considered to be risk factors for inducing
psoriasis.7–9 One reason for male predominance may partly be
because women have lower rates of drinking and smoking as
shown in our analysis as well as others.10,11
Several researchers including us have found that the risk of
developing psoriasis increases as the degree of obesity
increases.2,12 In this study, we did not find a difference
between men’s BMI and women’s. This fact indicates that pso-
riatic women in the FUPR had relatively larger BMI than non-
psoriatic women, because women had significantly smaller
BMI in the general Japanese and Fukuoka City population.2
We previously assessed the BMI of patients in the FUPR.2
The results showed that female psoriatic patients had the high-
est BMI between the ages of 20 and 39 years, while male pso-
riatic patients had a BMI higher than that of the controls over
the age of 40 years.2 This observation indicates that women
do not have metabolic syndrome or psoriasis in younger gener-
ations unless they have an extremely high BMI. For women in
their 20s, estrogen acts as an anti-metabolic hormone, and the
onset of metabolic diseases as well as psoriasis is suppressed.
However, decreased estrogen after menopause may allow
women to acquire late-onset psoriasis in their 50s.13 Employing
the onset age-specific rate of psoriasis with age-population
adjustment clearly revealed that female patients with earlier
onset were of higher proportion than male patients. We do not
know the reason, but we found the difference in familial
psoriasis.
We discovered that only female patients with early onset
have a higher incidence of familial psoriasis. This explains that
among young women with fewer risk factors such as smoking
and obesity, genetic predisposition has a stronger effect. This
trend was seen only in women with early onset and not in late
onset. The susceptible age of a disease rarely becomes bimo-
dal. In this study, the onset age of psoriatic patients had a

Table 2. Age of onset of psoriasis and incidence of familial psoriasis

Male (%) Female (%)

Probands
Probands Probands without
Age of onset Probands with without with family family
(years) n family history family history P n history history P Total
0–9 15 (1) 1 (3) 14 (2) >0.05 15 (1) 2 (6) 13 (4) >0.05 30 (3)
10–19 59 (5) 5 (13) 54 (8) >0.05 52 (5) 10 (31) 42 (12) <0.0073* 111 (10)
20–29 124 (11) 5 (13) 119 (17) >0.05 56 (5) 7 (22) 49 (15) >0.05 180 (16)
30–39 156 (14) 14 (37) 142 (20) <0.0217* 45 (4) 4 (13) 41 (12) >0.05 201 (18)
40–49 113 (10) 7 (18) 106 (15) >0.05 44 (4) 5 (16) 39 (12) >0.05 157 (14)
50–59 125 (11) 4 (11) 121 (17) >0.05 66 (6) 3 (9) 63 (19) >0.05 191 (17)
60–69 97 (9) 1 (3) 96 (13) <0.0485* 50 (4) 1 (3) 49 (15) >0.05 147 (13)
70–79 46 (4) 1 (3) 45 (6) >0.05 26 (2) 0 (0) 26 (8) >0.05 72 (6)
80–89 14 (1) 0 (0) 14 (2) >0.05 11 (1) 0 (0) 11 (3) >0.05 25 (2)
90–99 2 (0.2) 0 (0) 2 (0.3) >0.05 4 (0.4) 0 (0) 4 (1) >0.05 6 (1)
Total 751 (67) 38 (100) 713 (100) >0.05 369 (33) 32 (100) 337 (100) >0.05 1120 (100)

*P < 0.05.

© 2018 Japanese Dermatological Association 3

B. Bayaraa and S. Imafuku

Table 3. Contingency table of early (<30 years) and late onset of psoriasis and incidence of familial psoriasis

Men Women Total

Age of
onset FH+ FH Total P Ratio FH+ FH Total P Ratio FH+ FH Total P Ratio
FUPR <30 11 187 198 0.7074 5.6 19 104 123 0.0026** 15.4 30 291 321 0.0091** 9.3
>30 27 526 553 4.9 13 233 246 5.3 40 759 799 5
Total 38 713 751 5.1 32 337 369 8.7 70 1050 1120 6.3

**P < 0.01. FH+, with a family history; FH , without a family history; FUPR, Fukuoka University Psoriasis Registry; M+W, men plus women.

characteristic bimodal distribution. Bimodal distribution may
reflect two clinical subtypes in psoriasis, namely early-onset
psoriasis and late-onset, particularly shown in female patients.
The low frequency of habitual risk factors and obesity in Japa-
nese women may have allowed a separate, late-onset peak to
be clearly seen.
In summary, among patients in the FUPR, the age of onset
is bimodal, and patients with a family history were seen at a
higher frequency among young people. Our analyses suggest
that Japanese psoriatic patients consist of multiple subtypes.
Larger studies with genetic analysis are expected.
ACKNOWLEDGMENTS: We thank all the members of the
Department of Dermatology, Fukuoka University, for maintaining the
excellent FUPR, and Professor Hisatomi Arima for providing sugges-
tions about epidemiological and statistical analysis.
10 Naldi L, Peli L, Parazzini F. Association of early-stage psoriasis with
CONFLICT OF INTEREST: None declared.
11 Wolkenstein P, Revuz J, Roujeau JC et al. Psoriasis in France and
REFERENCES
12 Jin YT, Zhang FY, Yang S et al. Combined effects of HLA-Cw6,
1 Kubota K, Kamijima Y, Sato T et al. Epidemiology of psoriasis and
palmoplantar pustulosis: a nationwide study using the Japanese
national claims database. BMJ Open 2015; 5: e006450.
13 Ceovic R, Mance M, Bukvic Mokos Z et al. Psoriasis: female skin
2 Naito R, Imafuku S. Distinguishing features of body mass index and
psoriasis in men and women in Japan: a hospital-based case-con-
trol study. J Dermatol 2016; 43: 1406–1411.
3 Imafuku S, Naito R, Nakayama J. Possible association of hepatitis
C virus infection with late-onset psoriasis: a hospital-based obser-
vational study. J Dermatol 2013; 40: 813–818.
4 Tsuruta N, Imafuku S, Narisawa Y. Hyperuricemia is an independent
risk factor for psoriatic arthritis in psoriatic patients. J Dermatol
2017; 44: 1349–1352.
5 Kawada A, Tezuka T, Nakamizo Y et al. A survey of psoriasis
patients in Japan from 1982 to 2001. J Dermatol Sci 2003; 31: 59–
64.
6 Takahashi H, Nakamura K, Kaneko F et al. Analysis of psoriasis
patients registered with the Japanese Society for Psoriasis
Research from 2002-2008. J Dermatol 2011; 38: 1125–1129.
7 Fortes C, Mastroeni S, Leffondre K et al. Relationship between
smoking and the clinical severity of psoriasis. Arch Dermatol 2005;
141: 1580–1584.
8 Emre S, Metin A, Demirseren DD et al. The relationship between
oxidative stress, smoking and the clinical severity of psoriasis. J Eur
Acad Dermatol Venereol 2013; 27: e370–e375.
9 Gerdes S, Zahl VA, Weichenthal M et al. Smoking and alcohol
intake in severely affected patients with psoriasis in Germany. Der-
matology 2010; 220: 38–43.
smoking and male alcohol consumption: evidence from an Italian
case-control study. Arch Dermatol 1999; 135: 1479–1484.
associated risk factors: results of a case-control study based on a
large community survey. Dermatology 2009; 218: 103–109.
body mass index and waist-hip ratio on psoriasis vulgaris in Chi-
nese Han population. J Dermatol Sci 2008; 52: 123–129.
changes in various hormonal stages throughout life–puberty, preg-
nancy, and menopause. Biomed Res Int 2013; 2013: 571912.

4 © 2018 Japanese Dermatological Association