Title: Global prevalence of sexual dysfunction in women with skin diseases: a systematic review
and meta-analysis
Version: 1 Date: 23 Nov 2024
Reviewer:  Ehsan Amini-Salehi
Reviewer's report:
Dear Editor,
Thank you for inviting me to review the manuscript titled "Global prevalence of sexual
dysfunction in women with skin diseases: a systematic review and meta-analysis." The authors
have conducted a systematic review and meta-analysis addressing a clinically relevant topic,
particularly given the psychological and quality-of-life burdens associated with skin diseases.
The study provides valuable insights into the global prevalence of female sexual dysfunction
(FSD) across different dermatological conditions, and its findings have potential implications
for patient care and policy-making. Below, I provide detailed comments categorized into clinical
and statistical/methodological aspects.
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Clinical Comments:
1. Scope of Diseases: While the manuscript includes a range of dermatological conditions, some
less common disorders like keratosis pilaris and lichen planus are given substantial weight in the
results. Clarify why these conditions were included despite their relatively small sample sizes
and limited global burden.
2. Psychological Implications: The discussion could elaborate more on how psychological
interventions, such as counseling or psychotherapy, can mitigate the impact of FSD in patients
with skin diseases.
3. Impact of Disease Severity: While prevalence rates are provided, the study does not
sufficiently differentiate between mild and severe cases of skin diseases. This distinction could
provide more actionable insights for clinicians.
4. Cultural and Regional Variations: The manuscript notes that a majority of the studies are from
Egypt and other specific regions. Discuss how cultural perceptions of skin diseases and sexual
health might influence the reported prevalence rates.
5. Potential Interventions: Highlight the potential for multidisciplinary approaches (e.g.,
collaboration between dermatologists, psychologists, and gynecologists) to address FSD in
women with skin diseases.
6. Assessment Tools: The discussion should compare the effectiveness and limitations of the
various tools (e.g., FSFI, DLQI, ASEX) used to assess FSD in different studies, as these might
affect the reported prevalence rates.
7. Vitiligo-Specific Insights: Since vitiligo had the highest reported prevalence of FSD, explore
possible mechanisms beyond physical appearance concerns, such as oxidative stress or immune
dysregulation, that may contribute to sexual dysfunction.
8. Role of Comorbidities: Discuss the role of common comorbidities like depression, anxiety,
or metabolic disorders in amplifying the prevalence of FSD in women with skin diseases.
9. Practical Recommendations: Provide more specific recommendations for healthcare providers
on screening for FSD in dermatological clinics.
10. Future Research Directions: The manuscript would benefit from a section on gaps in the
current literature, such as the need for longitudinal studies to assess causality between skin
diseases and FSD.
Statistical and Methodological Comments:
1. Heterogeneity Management: The manuscript reports substantial heterogeneity in several
analyses (e.g., I² > 90%). Provide more detailed explanations of how this heterogeneity was
addressed and its potential impact on the robustness of the findings.
2. Subgroup Analyses: The subgroup analyses based on continents and tools used are
informative. However, discuss whether these differences are statistically significant and if they
affect the generalizability of the findings.
3. Publication Bias: While Begg and Mazumdar’s test indicated no significant publication bias,
consider including a trim-and-fill analysis to validate this conclusion further.
4. Quality Assessment Transparency: The manuscript references the STROBE checklist for
quality assessment but does not provide a summary table of the quality scores for the included
studies. Adding this would enhance transparency.
5. Fixed vs. Random Effects: The results of both fixed and random-effects models are presented.
Explain why the random-effects model was ultimately chosen for the primary analysis,
particularly in light of the high heterogeneity.
General Suggestions:
• Improve figure legends for forest plots and subgroup analyses to make them more reader-
friendly.
• Include a supplementary table summarizing the characteristics of the included studies,
particularly focusing on assessment tools and prevalence rates.
• Ensure consistent terminology throughout the manuscript (e.g., FSD vs. sexual dysfunction).
• Expand the limitations section to address the exclusion of non-English studies and potential
biases in the selection process.
I appreciate the opportunity to review this manuscript and hope these comments will help the
authors refine their work.
Best regards