Quality of life in patients with psoriasis and psoriasis arthritis with a special focus on stigmatization experience

Stigma associated with cutaneous leishmaniasis in rural Sri Lanka: development of a conceptual framework

BACKGROUND

There is limited knowledge about the stigma associated with cutaneous leishmaniasis (CL) in Sri Lanka. To ensure that leishmaniasis researchers focus on CL-associated stigma, we provide an evidence-based framework that can be used in future research.

METHODS

We conducted a systematic review on CL-associated stigma using international evidence and carried out a multimethod qualitative study in the Anuradhapura district in Sri Lanka. Based on that, we identified manifestations of stigma, drivers and facilitators that we synthesised to develop a conceptual framework on CL-associated stigma.

RESULTS

Our framework consists of drivers, facilitators and self-stigma experienced by people with CL. Stigma drivers included fear, misbeliefs and misconceptions about CL; the belief that wounds are disfiguring; the treatment burden and implied blame. Facilitators that reduced stigma included knowledge of the curability of CL and awareness that CL is not contagious. The nature of social interactions in rural communities enhanced stigma formation. We identified various enacted, felt and internalised stigma experiences of people with CL.

CONCLUSIONS

We developed a conceptual framework of the stigma associated with CL that can be used to develop targeted interventions to increase CL awareness, address stigma and improve the quality of life for CL patients.

Stigma, seizure self-efficacy, and quality of life in children with epilepsy

INTRODUCTION

In addition to seizure care, it has been well-established that a holistic approach to the treatment of children with epilepsy that addresses the social, behavioral, and psychological dimensions also benefits their quality of life (QoL). The aim of this study was to investigate the patient and parental perceived stigma, seizure self-efficacy of children with epilepsy, and the relationship with quality of life in terms of sociodemographic and epilepsy-related factors.

METHOD

The study group consisted of children, aged between 8 and 18 years and with a diagnosis of epilepsy of at least six months duration and their parents. Pediatric Quality of Life Inventory (PedsQL), Child-Parent Stigma Scales, and the Seizure Self-Efficacy Scale for Children (SSES-C) were used for evaluation.

RESULTS

One hundred and forty-four children (mean age 12.6 ± 2.9 years) took part, of whom 48.6% were female. The mean Child Stigma Scale score was 1.77 ± 0.82, Parent Stigma Scale score 2.41 ± 0.75, SSES-C score was 3.37 ± 0.98, and PedsQL score was 72.8 ± 18.6 for children self-reports (CsR) and 73.2 ± 18.8 for parent proxy-reports. The intraclass correlation coefficient for parent-child PedsQL indicated a good level of agreement. There was a significant negative correlation between the Child Stigma Scale and the PedsQL-CsR scores. A significant positive correlation was identified between the SSES-C scores and the PedsQL-CsR scores.

DISCUSSION

Perceptions of stigma in children with epilepsy and their parents were high in this study population. Of note, the elevated stigma perception reported by the patients had a detrimental impact on seizure self-efficacy. This relationship may affect the children's QoL and further complicates epilepsy management in this patient group.

Reaction to Disease and Coping Strategies in Stressful Situations among Psoriasis Patients: Cross-Sectional Study

Background: In the contemporary world, a cult of perfection is being created, and deviations from such an ideal image are becoming socially unacceptable. A particular situation arises when a defect or symptoms of a disease appear on the skin, which, in the case of people suffering from psoriasis, are a source of stress, dissatisfaction with the disease, and a reduction in quality of life. The aim of this study was to assess whether the quality of life related to the occurrence of psoriasis and the level of acceptance of the disease affect coping strategies in stressful situations. Methods: The study involved 111 people with common psoriasis (46.8% women and 53.2% men). Inclusion criteria were as follows: a diagnosis of common psoriasis for at least 0.5 years, no other types of psoriasis, no mental illnesses, and an informed consent of the respondent to participate in the study. In order to compile the research input, a proprietary questionnaire was used along with the following standardised tools: the Dermatology Life Quality Index (DLQI), the Acceptance of Illness Scale (AIS), and the Coping Inventory for Stressful Situations (CISS). Results: The duration of the disease in the studied population varied and ranged from 0.5 years to over 50 years. Most respondents showed relatively low DLQI scores, with an average value of 10.8 points. In stressful situations (CISS), the respondents primarily used a strategy based on rational thinking (Task-oriented coping), with approximately 54 points on average; followed by an avoidant style (Avoidance-oriented coping), with approximately 50 points on average; and least often an emotional style (Emotion-oriented coping), with approximately 46 points on average. The average level of disease acceptance (AIS) in the studied group equalled approximately 26 points. Conclusions: Psoriatic lesions on the torso caused less rational behaviour in stressful situations (a decrease in the Task-oriented coping) in women but had the opposite result in men, whereas psoriatic lesions on the head stimulated the use of Task-oriented coping in women but had the opposite result in men. The higher the acceptance of the disease (AIS) presented by the respondents, the less often they used an emotional strategy (Emotion-oriented coping) in stressful situations. The higher the quality of life (DLQI) was, the lower the values of Emotion-oriented coping were noted.

Exploring disease-related and treatment-related issues and concerns experienced by adults with spondyloarthritis, inflammatory bowel disease and psoriasis to identify unmet needs: a qualitative clinical concept mapping study

OBJECTIVES

Exploring patients' perspectives for significant factors of relevance in living with a chronic disease is important to discover unmet needs and challenges. The primary objective of this study was to explore disease-related and treatment-related issues and concerns experienced by adults with spondyloarthropathies (SpA) and associated diseases. As a secondary objective, we wanted to explore whether these factors were generic or disease dependent.

DESIGN

We used group concept mapping (GCM), a validated qualitative method, to identify disease-related and treatment-related issues and concerns. Participants generated statements in the GCM workshops and organised them into clusters to develop concepts. Furthermore, participants rated each statement for importance from 1: 'not important at all' to 5: 'of great importance'.

SETTING

Participants were recruited during routine care at the outpatient clinic at the hospitals in the period from May 2018 to July 2022.

PARTICIPANTS

Eligible participants were adults ≥18 years and diagnosed with axial spondyloarthritis (AxSpA), psoriatic arthritis (PsA), psoriasis (PsO) or inflammatory bowel disease -split into Crohn's disease (CD) and ulcerative colitis (UC).

RESULTS

52 patients participated in the 11 workshops divided into groups according to their diagnosis. They created a total of 1275 statements that generated 10 AxSpA concepts, 7 PsA concepts, 7 PsO concepts, 10 CD concepts and 11 UC concepts. The highest rated concepts within each disease group were: AxSpA, 'lack of understanding/to be heard and seen by healthcare professionals' (mean rating 4.0); PsA, 'medication (effects and side effects)' (mean rating 3.8); PsO, 'social and psychological problems, the shame' (mean rating 4.0); CD, 'positive attitudes' (mean rating 4.3) and UC; 'take responsibility and control over your life' (mean rating 4.0).

CONCLUSION

People with SpA and associated diseases largely agree on which concepts describe their disease-related and treatment-related issues and concerns with a few of them being more disease-specific.

Stigma associated with cutaneous and mucocutaneous leishmaniasis: A systematic review

BACKGROUND

Cutaneous (CL) and mucocutaneous leishmaniasis (MCL) are parasitic diseases caused by parasites of the genus leishmania leading to stigma caused by disfigurations. This study aimed to systematically review the dimensions, measurement methods, implications, and potential interventions done to reduce the CL- and MCL- associated stigma, synthesising the current evidence according to an accepted stigma framework.

METHODS

This systematic review followed the PRISMA guidelines and was registered in PROSPERO (ID- CRD42021274925). The eligibility criteria included primary articles discussing stigma associated with CL and MCL published in English, Spanish, or Portuguese up to January 2023. An electronic search was conducted in Medline, Embase, Scopus, PubMed, EBSCO, Web of Science, Global Index Medicus, Trip, and Cochrane Library. The mixed methods appraisal tool (MMAT) was used for quality checking. A narrative synthesis was conducted to summarise the findings.

RESULTS

A total of 16 studies were included. The studies report the cognitive, affective, and behavioural reactions associated with public stigma. Cognitive reactions included misbeliefs about the disease transmission and treatment, and death. Affective reactions encompass emotions like disgust and shame, often triggered by the presence of scars. Behavioural reactions included avoidance, discrimination, rejection, mockery, and disruptions of interpersonal relationships. The review also highlights self-stigma manifestations, including enacted, internalised, and felt stigma. Enacted stigma manifested as barriers to forming proper interpersonal relationships, avoidance, isolation, and perceiving CL lesions/scars as marks of shame. Felt stigma led to experiences of marginalisation, rejection, mockery, disruptions of interpersonal relationships, the anticipation of discrimination, fear of social stigmatisation, and facing disgust. Internalised stigma affected self-identity and caused psychological distress.

CONCLUSIONS

There are various manifestations of stigma associated with CL and MCL. This review highlights the lack of knowledge on the structural stigma associated with CL, the lack of stigma interventions and the need for a unique stigma tool to measure stigma associated with CL and MCL.

Factors associated with worsened clinical symptoms of psoriasis and disease-related quality of life during the COVID-19 lockdown: A cross-sectional study

Objective

In this cross-sectional study, we aimed to evaluate the factors associated with psoriasis symptom worsening and impaired quality of life (QoL) in individuals with psoriasis during the COVID-19 pandemic lockdown.

Methods

During the second COVID-19 national lockdown (January-April 2021) in Lithuania, individuals diagnosed with psoriasis were invited to fill in an anonymous online survey including sociodemographic and life-style factors, psoriasis-related clinical symptoms, the Dermatology Life Quality Index (DLQI) and the Patients' Health Questionnaire (PHQ).

Results

A total of 297 respondents completed the survey. The majority of them (52.5%) reported worsened clinical symptoms of psoriasis during the COVID-19 lockdown period. In total, 43.1% of responders reported significant depressive symptoms (PHQ-9 ≥ 10) and 23.6% reported impaired disease-related QoL (DLQI > 10). The strongest predictor of psoriasis symptoms worsening was the need for changes in psoriasis treatment, with an odds ratio (OR) of 2.73 (95% CI 1.37-5.44, p = 0.004) and decreased income (OR = 2.33, 95% CI 1.30-4.17, p = 0.004). The strongest predictor of impaired QoL was male sex (OR = 3.35, 95% CI 1.70-6.59, p < 0.001). Contribution of specific depressive symptoms was evident for both models.

Conclusion

Worsening of psoriasis symptoms during the COVID-19 lockdown was associated with decreased income, psoriasis treatment changes and depression symptoms. Impaired QoL was associated with male sex, symptom worsening and depression. Specific depression symptoms may have contributed to more symptom worsening and impaired QoL than the depressive symptomatology as a whole.

Mapping ethical and social aspects of biomarker research and its application in atopic dermatitis and psoriasis - A systematic review of reason

Biomarker research is associated with high hopes for atopic dermatitis/psoriasis research. Although various effective treatments have been developed, many challenges remain concerning diagnostics and the development of targeted treatments, but also regarding a number of ethical and social issues. In this paper, building on a systematic literature review and review of reason, we examine the ethical and social debate on biomarker research for atopic dermatitis/psoriasis. We discuss topics such as risks and benefits of stratification of patient groups, ethical aspects of big data and advanced analytics for biomarker use in atopic dermatitis/psoriasis. Our systematic literature review of reason, based on established methodological standards, includes argument-based ethics publications and scientific literature with implicitly ethically relevant aspects. The first search of biomarker research in dermatology and adjacent fields (e.g., oncology) resulted in a large amount of literature concerning general normative aspects of biomarker research, but suggested a lack of explicit argument-based ethical literature in atopic dermatitis/psoriasis research. We therefore conducted a second systematic search, focusing specifically on atopic dermatitis/psoriasis biomarker research. The 43 relevant articles identified through both systematic searches were clustered into three topic groups: (1) ethical aspects of stratification and precision medicine, (2) digital ethics, and (3) research ethics with a focus on complexity and validation. We found that compared to other fields, such as cancer research, the ethical aspects of atopic dermatitis/psoriasis are rarely explained and addressed in detail. In particular, more work is required on scientific standards, digital ethics and responsible clinical application of biomarkers for atopic dermatitis/psoriasis, patient participation, and ethical implications of biomarker use for children or young people with atopic dermatitis/psoriasis. We close with suggestions on how to address the ethical and social dimension of atopic dermatitis/psoriasis research and practice more directly in future.

Self-disgust in Patients with Dermatological Diseases

BACKGROUND

Dermatological diseases can be associated with symptoms such as oozing pus, weeping, and/or bleeding, which represent primary disgust elicitors. This study examined the role of self-disgust in people with different skin conditions (e.g., hidradenitis suppurativa, psoriasis, lichen sclerosus).

METHODS

A self-selected sample of 200 dermatology patients completed questionnaires for the assessment of self-disgust, experienced stigmatization, symptoms of depression, anxiety, and somatization. Multiple regression analysis and mediation analysis were computed to examine the relationship between self-disgust and the other selected variables.

RESULTS

Sixty-four percent of the patients reported elevated self-disgust. Sex, age, depression, and perceived stigmatization were predictors of self-disgust. Depression mediated the relationship between stigmatization (e.g., staring by others) and self-disgust.

CONCLUSIONS

This study points to the important role of self-disgust in dermatological conditions. Public health programs to counteract stigmatization of patients with skin diseases as well as therapy approaches that help decrease patients' self-disgust and increase self-acceptance are urgently needed.

The Impact of Stress-Coping Strategies and the Severity of Psoriasis on Self-Esteem, Illness Acceptance and Life Satisfaction

Introduction

The visibility of skin lesions is a significant burden for patients with psoriasis, who experience social hostility as well as many emotional and psychological problems. The recurrent nature of cutaneous manifestations and their location are also a source of emotional distress, which in turn is one of the main factors that intensifies skin lesions in these patients. The aim of the study was to assess the impact of the severity of psoriasis and stress-coping strategies on general psychometric measures in the affected patients.

Methods

The study used a short demographic questionnaire, Psoriasis Area and Severity Index (PASI), and four standardised general psychometric tools: Rosenberg Self-Esteem Scale (SES), Satisfaction With Life Scale (SWLS), Coping Inventory for Stressful Situations (CISS) and Acceptance of Illness Scale (AIS). A total of 111 patients participated in the study.

Results

The mean PASI score was 14.0 (12.1–15.9). The mean SWLS score was below average, i.e., 18.5 (17.3–19.7), and the SES score—26.8 points (26.1–27.5)—indicated self-esteem slightly above average among patients with psoriasis. The mean stress-coping level measured with CISS was 53.6 (51.9–55.2) for the task-oriented strategy (TOS), 46.2 (43.8–48.6) for the emotion-oriented strategy (EOS) and 50.1 (48.5–51.8) for the avoidance-oriented strategy (AOS). Higher PASI was associated with lower illness acceptance among men (r = 0.48) and lower self-esteem among women (r = 0.44). The level of life satisfaction was lower in respondents with higher PASI scores (mainly in the group of women, r = 0.44).

Conclusions

Higher severity of psoriasis (PASI) and greater frequency of emotion-oriented stress-coping mechanisms (CISS) are factors that negatively affect the overall psychophysical condition of respondents.

Skin-Disease Specific and Generic Psychometric Measures in Patients with Psoriasis

INTRODUCTION

Psychosocial problems of patients with chronic dermatoses, such as psoriasis, add to their somatic ailments, which results in the lack of illness acceptance, lowered self-esteem, deteriorated quality of life, and an array of somatic comorbidities. The aim of this study was to analyze the effect of psoriasis on the quality of life, sense of stigmatization, self-esteem, and satisfaction with life in patients with psoriasis.

METHODS

The study was based on a short survey prepared by the authors and five validated scales: Dermatology Life Quality Index (DLQI), 6-Item Stigmatization Scale, 33-Item Feelings of Stigmatization Questionnaire, Rosenberg Self-Esteem Scale (SES), and Satisfaction With Life Scale (SWLS). The study included 111 patients with psoriasis (46.8% women and 53.2% men). The inclusion criteria of the study were the diagnosis of plaque psoriasis and written informed consent to participate.

RESULTS

DLQI scores ranged between 0 and 28 points (pts) (mean 10.8 pts). Mean stigmatization scores determined with the 33- and 6-Item Stigmatization Scale were 81.6 pts and 7.5 pts, respectively. The mean SWLS score for the study group (18.5 pts) was slightly below the average. The mean score SES of 27 pts implies that the study respondents' self-esteem level was slightly above the average.

CONCLUSIONS

Satisfaction with life turned out to be significantly modulated by overall stigmatization level on the 33-Item Stigmatization Scale (the stronger the sense of stigmatization, the lower the satisfaction with life) and education (respondents with higher education presented with higher satisfaction with life than those with non-higher education).

Impact of an eHealth Smartphone App on the Mental Health of Patients With Psoriasis: Prospective Randomized Controlled Intervention Study

Background

Psoriasis has a negative impact on patients’ physical and mental health and can lead to anxiety and depression. Disease management strategies, including educational programs and eHealth devices, have been shown to improve health care for several chronic diseases. However, such disease management strategies are lacking in the routine care of patients with psoriasis.

Objective

This study aims to study the impact of a novel intervention that combines an educational program with a disease management smartphone app on the mental health of patients with psoriasis.

Methods

Patients with psoriasis in the intervention group received an educational program; attended visits on weeks 0, 12, 24, 36, and 60; and had access to the study app. Patients in the control group only attended the visits. The primary endpoint was a significant reduction of scores on the Hospital Anxiety and Depression Scale (HADS). Secondary end points were reductions in Dermatology Life Quality Index score, Psoriasis Area and Severity Index score, pruritus, and pain, as well as improvements in mood and daily activities. In addition, modulating effects of sex, age, disease duration, and app use frequency were evaluated.

Results

A total of 107 patients were included in the study and randomized into the control group (53/107, 49.5%) or intervention group (54/107, 50.5%). Approximately 71.9% (77/107) of the patients completed the study. A significant reduction in HADS-Depression (HADS-D) in the intervention group was found at weeks 12 (P=.04) and 24 (P=.005) but not at weeks 36 (P=.12) and 60 (P=.32). Patient stratification according to app use frequency showed a significant improvement in HADS-D score at weeks 36 (P=.004) and 60 (P=.04) and in HADS-Anxiety (HADS-A) score at weeks 36 (P=.04) and 60 (P=.05) in the group using the app less than once every 5 weeks. However, in patients using the app more than once every 5 weeks, no significant reduction in HADS-D (P=.84) or HADS-A (P=.20) score was observed over the 60-week study period compared with that observed in patients in the control group. All findings were independent of sex, age, and disease duration.

Conclusions

These findings support the use of a disease management smartphone app as a valid tool to achieve long-term improvement in the mental health of patients with psoriasis if it is not used too frequently. Further studies are needed to analyze the newly observed influence of app use frequency.

Trial Registration

Deutsches Register Klinischer Studien DRKS00020755; https://tinyurl.com/nyzjyvvk

'Your face freezes and so does your life': A qualitative exploration of adults' psychosocial experiences of living with acquired facial palsy

OBJECTIVES

Facial palsy (FP) is a highly visible appearance-affecting condition and can have a significant impact on facial function. Qualitative research focussing on adults' experiences of living with acquired FP is limited. This study aimed to explore the psychosocial impact of acquired FP and to gain a greater understanding of patients' experiences of treatment and care in the United Kingdom.

DESIGN

A qualitative interview study with individuals living with acquired FP.

METHODS

Ten adults with acquired FP were recruited. Their experiences were explored using semi-structured telephone interviews. Data were analysed using thematic analysis.

RESULTS

Five master themes were identified through the thematic analysis: 1) grappling with a new identity, 2) the psychosocial impact of living with facial palsy, 3) isolation: dealing with 'one hell of a problem on your own', 4) a life on hold, 5) coping strategies. Findings indicated high levels of distress and significant challenges in managing the functional and psychosocial changes associated with acquiring FP. Participants expressed grief for their former appearance and identity, with photographs and mirrors acting as agonizing reminders. Many reported a sense of abandonment due to uncoordinated care and, as a result, engaged in an endless and often fruitless pursuit to gain control over FP by experimenting with their own treatment. Many reported the negative impact of their altered facial expressions on social interactions and a fear of being negatively evaluated.

CONCLUSIONS

This study highlights a pressing need to review how FP is managed in the UK. To improve patient well-being, health care professionals could benefit from FP education, and patients from timely access to psychological support and clearer standards of care following diagnosis.

Effect of Disease Severity on the Quality of Life and Sense of Stigmatization in Psoriatics

INTRODUCTION

Psoriasis is a chronic inflammatory disease of the skin having a profound effect on the quality of life and contributing to the sense of stigmatization in the affected patients. The aim of this study was to analyze the effect of psoriasis severity on the quality of life and sense of stigmatization in psoriatics and to investigate relationships between these measures and sociodemographic variables.

PATIENTS AND METHODS

The study included 111 patients with psoriasis. The inclusion criteria of the study were the diagnosis of psoriasis and written informed consent to participate. The study was based on a short survey prepared by the authors and four validated scales: Dermatology Life Quality Index (DLQI), 6-item Stigmatization Scale, 33-item Feelings of Stigmatization Questionnaire, and Psoriasis Area and Severity Index (PASI).

RESULTS

Mean PASI score for the study group was 14 pts. Most respondents presented with low DLQI scores, with the mean value of 10.8 pts suggesting that the disease-related ailments were not extremely burdensome for the majority of the patients. Mean stigmatization scores for the 6- and 33-item scale were 7-8 and 81-82 pts, respectively.

CONCLUSION

The severity of psoriasis was the strongest determinant of the quality of life measured with the DLQI. Also, the levels of stigmatization determined with the 6- and 33-item scale correlated significantly with PASI scores.

Feeling of stigmatization and satisfaction with life among Arabic psoriatic patients

BACKGROUND

Satisfaction and stigmatization are experienced differently in different cultural contests, especially, in patients with dermatological diseases affecting visible body parts. Reports in Arabic countries remain rare and very appealing in a multicultural population.

AIMS

To evaluate feeling of stigmatization and satisfaction with life in Arabic patients with psoriasis and identify predictors of feeling of stigmatization and satisfaction with life.

METHODS

In a cross-sectional study design, Arabic patients with psoriasis completed the 6-item stigmatization scale and the satisfaction with life scale. Univariate and forward stepwise multivariate linear regression analyses were used to identify predictors of feeling of stigmatization and satisfaction with life. Covariates included patients' demographics (age, gender and education level), disease-related factors (disease severity, visibility, duration, and impact on quality of life) and patient-related factors (illness acceptance and dermatology self-care education level).

RESULTS

In total, 199 Arabic psoriatic patients were included in the study. Despite feeling highly stigmatized by their skin disease [mean (95% Confidence Intervals (CI)) of 7.0 (6.3-7.7)], psoriasis patients were generally positive about their overall satisfaction with life (mean (95% CI) of 21.0 (20.0-22.3). Impaired quality of life was the strongest predictor of both higher feeling of stigmatization (β-coefficient 0.39, 95% CI 0.30, 0.47) and less satisfaction with life (-0.36, 95% CI -0.53, -0.20). Higher levels of dermatology self-care education significantly predicted a lower feeling of stigmatization (-0.09, 95% CI -0.16, -0.01). Older patients (0.18, 95% CI 0.05, 0.30) and those with higher illness acceptance levels (0.14, 95% CI 0.03, 0.24) were more satisfied with life.

CONCLUSIONS

A level of stigmatization was detected in most psoriatic patients including the satisfied ones. Patients with more impaired quality of life experienced higher level of stigmatization and less satisfaction with life. These findings further enforce the multidisciplinary approach in psoriatic patients and highlight the unmet need to include psychologist in the therapeutic algorithm.

Effects of disease severity on quality of life in patients with psoriasis

Psoriasis is one of the leading dermatological diseases that can result in degradation in quality of life (QOL). We aimed to evaluate the effects of disease severity on QOL in psoriasis patients living in our region. Fifty-nine female and 41 male patients diagnosed with psoriasis were included in the study. The Psoriasis Area Severity Index (PASI) was used to determine disease severity. The Psoriasis Quality of Life Questionnaire (PQLQ) was used to evaluate QOL. The mean PASI score was 14.3 ± 10.1. The PQLQ and subscale scores were not affected by age, marital status, educational status, or age at onset of the disease etc. parameters (P > .05). Additional drug use, joint involvement, and lesion site exposure were found to increase psychosocial negativity scores significantly (P < .05). The mean scores for difficulties in daily life and treatment problems were significantly higher in men than in women (P < .05). There was a positive correlation between PASI scores and PQLQ, PQLQ subgroup scores. We found that QOL decreased with increasing severity of the disease. QOL as well as clinical severity should be considered in the planning and follow-up of psoriasis treatment. To evaluate the QOL, we believe that the PQLQ can be used as demonstrated in our study.

Anticipated and Perceived Stigma Among Patients With Psoriasis

BACKGROUND

Perceived stigma among patients with psoriasis (PWP) is associated with poorer quality of life.

OBJECTIVE

To determine the prevalence and predictors of stigmatizing attitudes that PWP expect and experience from others.

METHODS

We conducted a survey using validated outcome measures to assess the extent to which PWP anticipate and perceive stigma from others. Demographic and clinical characteristics were obtained from electronic medical records.

RESULTS

Patients (n = 106) were 48.11% female, 70.75% white, and had a mean age ± SD of 47.90 ± 16.19 years old. Of all, 25.47% self-reported their psoriasis as severe. Mean physician global assessment score ± SD was 2.98 ± 1.81. Two-thirds (66.98%) of patients reported that, in response to seeing their psoriasis-affected skin, they anticipated others to stereotype them as "contagious." Linear regression analyses demonstrated that patient-reported severe psoriasis, compared to mild psoriasis, was associated with greater anticipation of negative stereotypes, social avoidance, and perceived stigma from others (P values < .05). Physician-measured body surface area and global assessment scores were not significantly associated with any outcome.

CONCLUSION

Prevalence of anticipated and perceived stigma among PWP is high. Our results suggest that objective measures of severity may not identify patients at risk of stigma-related distress. Additional methods, such as directly inquiring about stigmatizing experiences, may be needed.

Emotions, Alexithymia, and Emotion Regulation in Patients With Psoriasis

Psoriasis is a chronic dermatological condition that is frequently associated with problematic patterns of emotional reactivity (the way in which patients react to stimuli), alexithymia (their ability to recognize and label the emotional reaction), and emotion regulation (the ability to enhance or reduce their own emotional reaction). A research in the peer-reviewed scientific literature was conducted in order to identify articles describing the association of psoriasis and affective problems. In particular, we first evaluate studies that have investigated abnormal emotional reactivity (in terms of duration, frequency, or type of the experienced emotions) and its impact on patients' quality of life; next, we review the role of alexithymia and emotion regulation in modulating the relationship between emotional reactivity and quality of life in this population. From a critical analysis of the reviewed studies, we highlight that altered emotional processing might be particularly important in the characterization of this condition. In particular, we show that this condition is related to an emotional reactivity characterized by negative emotions that have a stronger impact on patients' quality of life when emotion regulation abilities are weak, especially if patients have alexithymia. Finally, we present suggestions for future directions in both clinical and research fields.

Acceptance of Illness, Satisfaction with Life, Sense of Stigmatization, and Quality of Life among People with Psoriasis: A Cross-Sectional Study

INTRODUCTION

Psoriasis is a complex disease with a heterogeneous presentation, which may have a profound effect on the everyday functioning of patients. As a strongly stressogenic disease, psoriasis may cause lack of illness acceptance and contribute to negative changes in self-image. Usually, psoriasis also has a detrimental effect on quality of life. The aim of this study is to determine the levels of illness acceptance, satisfaction with life, stigmatization, and quality of life in people with psoriasis, to analyze relationships among these variables, and to verify whether they are modulated by selected sociodemographic factors.

METHODS

A total of 366 people with psoriasis treated at the Dermatology and Medical Cosmetology Clinic in Białystok were included. The study was conducted using a short survey prepared by the authors and five validated psychometric scales: Acceptance of Illness Scale (AIS), Satisfaction with Life Scale (SWLS), 6-item Stigmatization Scale, 33-item Feelings of Stigmatization Questionnaire, and Dermatology Life Quality Index (DLQI).

RESULTS

Median AIS score was 24 pts, which corresponds to a moderate level of illness acceptance. The level of illness acceptance among men was significantly higher than among women. More than half of respondents assessed their satisfaction with life as low. Men showed low levels of satisfaction with life slightly more often than women. Patients living in the countryside showed high levels of satisfaction with life significantly more often than those living in cities/towns. Mean scores for the 6-item Stigmatization Scale and the 33-item Feelings of Stigmatization Questionnaire were 8.73 pts and 90.06 pts, respectively, with no significant differences between the results of male and female patients. The DLQI scores for the study group ranged between 0 and 30 pts, with the mean value of 17.81 pts corresponding to a severe deterioration of quality of life. Statistically significant differences between quality of life and all sociodemographic variables were demonstrated.

CONCLUSIONS

People with psoriasis participating in this study showed moderate levels of illness acceptance and stigmatization, low level of satisfaction with life, and moderately deteriorated quality of life. Acceptance of illness was significantly modulated by patient sex. The level of illness acceptance among men was significantly higher than among women. Furthermore, illness acceptance exerted a significant effect on satisfaction with life in psoriasis patients. Place of residence exerted significant effects on satisfaction with life (higher in countryside dwellers), sense of stigmatization (stronger in countryside dwellers), and quality of life (more severely deteriorated in city/town dwellers). Disease duration significantly affected the degree of life satisfaction, sense of stigmatization (measured using a 33-item Feelings of Stigmatization Questionnaire), and quality of life among patients with psoriasis.

Psychological Distress, Alexithymia and Alcohol Misuse in Patients with Psoriasis: A Cross-Sectional Study

This study investigates (a) the prevalence of psychological distress, alexithymia and alcohol misuse in psoriasis patients; and (b) the relationship between psoriasis severity, alexithymia, alcohol and psychological distress in patients with psoriasis. A cross-sectional study was conducted. Outpatients (n = 184) with moderate to severe psoriasis completed a psychological screening battery. Measures included the Hospital Anxiety and Depression Scale, the Penn State Worry Questionnaire, the twenty-item Toronto Alexithymia Scale, the Dermatology Life Quality Index, the Psoriasis Area and Severity Index, the Self-Administered Psoriasis Area and Severity Index, and the Alcohol Use Disorders Identification Test. Demographic, clinical details and information on knowledge of psychosocial issues, alcohol and confidence on coping with distress and talking to others about psoriasis was also gathered. Alexithymia was associated with anxiety, depression and worry; subjective psoriasis severity was associated with worry. Alcohol misuse was related to anxiety and worry, but not to depression. Appropriate identification and treatment of alcohol difficulties and psychological distress of patients with psoriasis is needed.

Perception and determinants of stigmatization of people with psoriasis in the German population

BACKGROUND

Perception of psoriasis in the general population is characterized by knowledge deficits and prejudice against those affected. The extent and possible predictors of stigmatizing attitudes remain unclear.

OBJECTIVES

The aim was to assess prejudices and stigmatization of people with psoriasis and to identify sociodemographic and attitude-related variables accounting for stigmatization.

METHODS

Representative telephone surveys of 2004 (in 2017) and 2001 (in 2018) adults using a standardized questionnaire. Descriptive analyses were applied to living area, age, gender, educational status, general knowledge and attitudes about psoriasis. Logistic regression analyses were carried out to determine which variables are associated with the assessment of prejudices of 'others' against people with psoriasis. Those prejudices were specified by the following statements: 'they should take better care of themselves', 'don't want to touch people with psoriasis' and 'disgusted by psoriasis'.

RESULTS

The majority of those surveyed (74%) believe that people with psoriasis are disadvantaged. Similarly, a majority (69%) said that most people find psoriasis disgusting, do not want to touch people with psoriasis (59%) and think that people with psoriasis need to take better care of themselves (45%). 'Willing to enter a relationship with an affected person' (OR = 0.330, P = 0.029), higher age (OR = 1.027, P <0.001) and male gender (OR = 1.263, P = 0.034) proved to be significantly associated with 'psoriasis is disgusting'. Education (OR = 1.648, P = 0.016) and lower age (OR = 0.847, P  <0.001) are significantly associated with 'they need to take better care of themselves'.

CONCLUSIONS

Data suggest that stigmatization of skin diseases is still entrenched. This overview shows the need for interventions against stigmatization of those affected. Results imply that gender, age and education level and related health literacy of the target groups of respective interventions should be taken into account.

Clinical Profile of Patients with Psoriasis and their Attitude Towards the Illness

Introduction: Psoriasis is a chronic inflammatory hyperproliferative disease of the skin and affects 0.6–4.8% of the world’s population. In addition to the skin and joint manifestations, psoriasis impairs many aspects of individual wellbeing, including emotional, physical, sexual, and financial status. Skin diseases such as psoriasis can profoundly influence a patient’s self-image, self-esteem, and sense of wellbeing. This study aimed to assess the clinical profile of patients with psoriasis and their attitude towards living with the disease. Methods: A cross-sectional descriptive design was used. Two hundred subjects diagnosed with psoriasis were recruited through purposive sampling. A structured proforma was used to assess the clinical profile and attitude was assessed by Psoriasis Attitude Assessment Questionnaire (PSAQ). Results: The most common type of psoriasis was chronic stable psoriasis (86.5%). A family history of psoriasis was present in 30 (15.0%) subjects. Stress was attributed to the exacerbation of disease in 90 (45.0%) subjects. Itching was reported by 124 (62.0%) subjects, and sleep disturbance was reported by 85 (42.5%) of the subjects. The majority of individuals (n: 187; 93.5%) had a moderately favourable attitude towards living with psoriasis. Conclusion: Living with psoriasis can be difficult for patients because of the inconvenience caused by the disease in their daily life. Knowledge about the pathogenesis and treatment of psoriasis may increase the patient’s perception of control and attention to aggravating factors may increase patient’s compliance with treatment and positive lifestyle habits.

Relationship between self-esteem and stigmatization in psoriasis patients

Introduction

Psoriasis is classified as a psychosomatic disease since its development and outcome may be modulated by various psychological factors. Due to the presence of clinical signs visible to others and poor social awareness of the disease, psoriasis patients are not infrequently classified as different or stigmatized, and their value as human beings tends to decrease.

Aim

To analyse the relationship between self-esteem and stigmatization in psoriasis patients.

Material and methods

The study included 120 patients with psoriasis vulgaris. The study participants completed Polish versions of the Rosenberg Self-Esteem Scale (RSES) and the 6-Item Stigmatization Scale developed by Evers et al., as well as an original survey containing questions about their sociodemographic characteristics.

Results

Mean RSES score of the study participants was 24.1 points. Mean RSES score for female patients was nearly 2 points lower than the mean score for men. Analysis of Spearman's rho coefficients showed that the higher the self-esteem in the study participants the less often they considered themselves unattractive to others (0.23), less often believed that people gaze at their skin lesions (0.23) or avoid them because of their condition (0.38).

Conclusions

Our findings demonstrate clearly that both self-esteem and stigmatization are significant components of psoriasis' influence on the patient life. Psoriasis should not be considered merely as a somatic problem, but also as a significant psychological and social burden.

Psoriasis patient preferences for topical drugs: a systematic review

BACKGROUND

Topical drugs are recommended first-line treatment for mild-to-moderate psoriasis. However, patient preferences for the topical drugs differ, since a wide variety of topical drugs and topical drug formulations are available.

OBJECTIVES

The aim of this study was to investigate psoriasis patient preferences for topical drugs.

METHODS

A systematic literature search was performed for English-language articles in Embase, Medline, PsycINFO, Cinahl, Scopus, and the Cochrane Library.

RESULTS

Four surveys, six randomized controlled trials, and two prospective studies of mainly good quality were included. Seven of the studies investigated patient preferences for topical drug formulations, while five studies investigated their preferences for different topical drugs. Overall, patients preferred drugs that are easy to apply, less messy, and have a pleasant scent.

CONCLUSION

Psoriasis patient preferences for topical drugs differ. There is no one topical drug or topical drug formulation that suits everyone, which shows the importance of individualized prescriptions for topical drugs that are based on shared decision-making between the prescriber and patient.

The stigma of skin disease

PURPOSE OF REVIEW

The effects of skin disease on stigmatization are important but understudied in the pediatric population. Given the highly visible nature of dermatologic conditions, stigmatization is a common problem that requires significant attention in patients with skin diseases. In this review, we examine the recent literature addressing stigmatization of patients suffering from common dermatologic diseases with the goal to increase clinician awareness of these issues and identify new avenues for future research.

RECENT FINDINGS

A number of studies have examined the impact of skin disease on psychosocial well being and quality of life. Although some skin diseases are often overlooked medically and considered to be primarily cosmetic issues, the long-term consequences of skin diseases on psychosocial health, especially in pediatric patients, can be profound.

SUMMARY

The precipitating factors for stigma vary widely depending on age, sex, and culture. In order to effectively reduce the impact of pediatric skin diseases on psychosocial health, physicians should be able to identify specific characteristics that may increase risks for stigmatization in chidlren. Carefully monitoring psychosocial development in pediatric patients with dermatological conditions in addition to proactively guiding patients and families to appropriate resources can benefit the child's development and overall long-term well being.

Stigmatizing attitudes toward persons with psoriasis among laypersons and medical students

BACKGROUND

Perceived stigma among patients with psoriasis contributes to poor quality of life.

OBJECTIVE

To determine the prevalence and predictors of stigmatizing attitudes toward persons with psoriasis among laypersons and medical trainees.

METHODS

Laypersons were recruited from Amazon.com's Mechanical Turk (MTurk) (n = 198). Additionally, 187 medical students were recruited via e-mail. Participants completed an online survey in which they viewed images of persons with visible psoriasis. Participants reported their desire to socially avoid the persons in the images, their emotional responses to the persons in the images, and their endorsement of psoriasis-related stereotypes and myths.

RESULTS

MTurk participants endorsed social avoidance items such as not wanting to shake hands with (39.4%) or have the persons in the images in their home (32.3%). Participants stereotyped persons with psoriasis as contagious (27.3%) and endorsed the myth that psoriasis is not a serious disease (26.8%). Linear regression analyses showed that having heard of or knowing someone with psoriasis predicted fewer stigmatizing attitudes (P < .05). The medical students reported less stigmatizing attitudes than the MTurk participants (P < .01).

LIMITATIONS

Self-report, single-institution study.

CONCLUSION

Stigmatizing views of persons with psoriasis are prevalent among people in the United States. Educational campaigns for the public and medical trainees may reduce stigma toward persons with psoriasis.

Comparison of mental health outcomes among adults with psoriasis on biologic versus oral therapies: a population-based study

PURPOSE

We sought to compare the impact of biologic versus oral therapies on mental health outcomes among adult U.S. residents with moderate-to-severe psoriasis.

METHODS

We performed a nationwide, cross-sectional study comparing 2,303,534 (weighted) adults with moderate-to-severe psoriasis on biologic versus oral therapies and their associated mental health outcomes using the 2003-2015 Medical Expenditure Panel Survey (MEPS). Mental health outcomes were measured with the Kessler 6 (K6), a validated measure of psychological distress, and Patient Health Questionnaire 2 (PHQ2), a screening tool for depression.

RESULTS

The mean K6 score for residents on biologic therapies was significantly lower than that of residents on oral therapies (2.72 [95% CI: 2.27-3.17] versus 3.70 [95% CI: 3.27-4.12]; p < .001). The mean PHQ2 score for residents on biologic therapies was also significantly lower than that of residents on oral therapies (0.540 [95% CI: 0.390-0.690] versus 0.890 [95% CI: 0.749-1.031]; p < .001). Based on adjusted multivariable linear regression models, biologic therapy was associated with significant reductions in K6 (p < .001) and PHQ2 (p = .016) scores compared to oral therapy.

CONCLUSIONS

Therapeutic choices for psoriasis impact mental health outcomes. Biologic therapy is associated with reductions in psychological distress and depression as compared to oral therapy in the U.S. adult moderate-to-severe psoriasis population.

Risk and predictors of psoriasis in patients with breast cancer: a Swedish population-based cohort study

BACKGROUND

The risk of psoriasis in patients with breast cancer is largely unknown, as available evidence is limited to case findings. We systematically examined the incidence and risk factors of psoriasis in patients with breast cancer.

METHODS

A Swedish nationwide cohort of 56,235 breast cancer patients (2001-2012) was compared to 280,854 matched reference individuals from the general population to estimate the incidence and hazard ratio (HR) of new-onset psoriasis. We also calculated HRs for psoriasis according to treatment, genetic, and lifestyle factors in a regional cohort of 8987 patients.

RESULTS

In the nationwide cohort, 599 patients with breast cancer were diagnosed with psoriasis during a median follow-up of 5.1 years compared to 2795 cases in the matched reference individuals. This corresponded to an incidence rate of 1.9/1000 person-years in breast cancer patients vs. 1.7/1000 person-years in matched reference individuals. Breast cancer patients were at an increased risk of psoriasis (HR = 1.17; 95% confidence interval (CI) = 1.07-1.28), especially its most common subtype (psoriasis vulgaris; HR = 1.33; 95% CI = 1.17-1.52). The risk of psoriasis vulgaris was highest shortly after diagnosis but remained increased up to 12 years. Treatment-specific analyses indicated a higher risk of psoriasis in patients treated with radiotherapy (HR = 2.44; 95% CI = 1.44-4.12) and mastectomy (HR = 1.54, 95% CI = 1.03-2.31). Apart from treatment-specific effects, we identified genetic predisposition, obesity, and smoking as independent risk factors for psoriasis in breast cancer patients.

CONCLUSIONS

The incidence of psoriasis is slightly elevated among patients with breast cancer, with treatment, lifestyle, and genetic factors defining the individual risk profile.

Toward a better understanding of social anxiety and depression in psoriasis patients: The role of determinants, mediators, and moderators

OBJECTIVE

To determine how and under which conditions psoriasis is related to the psychological impairments, in particular, to social anxiety and depression, the current study tested the interplay of selected factors such as gender, age of onset of psoriasis, cognitive and affective elements of body image, experiences of stigmatization, and patients' subjective perceptions of severity of the disease.

METHODS

Adult psoriasis patients (N=193) completed the Appearance Schemas Inventory-Revised, the Stigmatization Scale, the Body Emotions Scale, the Beck Depression Inventory, and the Social Anxiety Questionnaire. The disease severity was defined based on the Body Surface Area (BSA) index.

RESULTS

The effect of psoriasis on social anxiety was moderated by age of onset: higher severity of the disease was associated with higher levels of social anxiety, but only for patients with pre-adult onset psoriasis. Hierarchical multiple regressions revealed that in patients with adult-onset (≥18years of age) the importance of appearance to one's sense of self-worth was the main contributor to social anxiety, while in patients with pre-adult onset, social anxiety was most strongly related to experiences of stigmatization. Moreover, the results indicated that negative body-related emotions mediated the relationship between severity of the disease and depression. Additionally, the relationship between severity of psoriasis and body image emotions was moderated by gender.

CONCLUSIONS

Findings significantly extend previous studies by confirming and highlighting the role of age of onset of psoriasis in psychological impairments, and provide more insight into factors that contribute to social anxiety in this group of patients.

The relationship between psoriasis and depression: A multiple mediation model

This study examined the relationship between psoriasis and depression, proposing a multiple mediation model to analyse the relationship. A total of 193 patients with psoriasis aged 20-67 years completed the Beck Depression Inventory, the Stigmatization Scale, the Appearance Schemas Inventory-Revised, and the Body Emotions Scale. The Body Surface Area index was used to assess severity of psoriasis. Serial multiple mediation analysis revealed that experiences of stigmatization, maladaptive beliefs about appearance and its salience to one's self-evaluation, and negative emotional attitudes towards the body, jointly, sequentially mediated the relationship between the presence of skin lesions of psoriasis and depressive symptoms. These results highlight the importance of the associations between stigmatization and cognitive and affective aspects of body image in relation to depression in patients with psoriasis. We suggest that prevention and intervention programs for psoriasis patients that target body image enhancement would be worthy of further research.

Considerations for Systemic Treatment of Psoriasis in Obese Patients

Psoriasis is an immune-mediated inflammatory skin disease frequently associated with metabolic disorders, including diabetes, dyslipidaemia and metabolic syndrome. Moreover, a growing number of studies confirm the association between psoriasis and obesity. It has been found that obesity, as measured by body mass index >30 kg/m², can double the risk of incident psoriasis. A positive correlation between different measures of adiposity and the severity of psoriasis has also been reported. Epidemiologic studies have also provided robust evidence confirming the association between obesity and psoriatic arthritis. Genetic, metabolic and environmental factors are all likely to contribute to these associations. Adipose tissue is an active endocrine and paracrine organ that has a key role in lipid and glucose metabolism as well as inflammation. Fat tissue is traditionally distributed into two main compartments with different metabolic characteristics, i.e. the subcutaneous and visceral adipose tissue. Particular attention has been devoted to visceral adiposity because of its contribution to inflammation and atherosclerosis. The association between psoriasis and obesity should be properly considered when choosing a systemic treatment, because it could exert negative effects on metabolic parameters, including liver enzymes, serum lipids and renal function. Obesity may increase the risk of liver and renal toxicity from methotrexate and cyclosporine. Moreover, obesity can compromise the effectiveness of systemic treatments for psoriasis (conventional and biological therapies). Dermatologists are also expected to promote a healthy lifestyle and weight loss for obese patients because they could improve metabolic parameters and responsiveness to psoriasis therapies.

Burden of Moderate-to-Severe Plaque Psoriasis and New Therapeutic Approaches (Secukinumab): An Italian Perspective

Abstract

Psoriasis is a chronic immune-mediated inflammatory skin disease commonly categorized as mild, moderate, or severe. Moderate-to-severe psoriasis is associated with significant comorbidity and has been shown to severely impair quality of life. Moreover, psoriasis is associated with high costs, including those associated with treatment, which have increased recently with the inclusion of biological systemic agents (most recently secukinumab) as available treatment options. However, despite clear evidence of their value in the treatment of moderate-to-severe plaque psoriasis, in Italy access to the biological agents remains limited to dermatological centers originally involved in the Psocare network. The impact of secukinumab entry into the market in Italy is still to be determined, but we believe that it will be associated with significant changes in the way in which biological treatments for psoriasis are accessed and prescribed in Italy. It is noteworthy that in January 2015, the European Medicines Agency approved secukinumab as first-line systemic therapy in this indication.

Funding

Novartis, Italy.

Incremental Costs for Psoriasis and Psoriatic Arthritis in a Population-based Cohort in Southern Sweden: Is It All Psoriasis-attributable Morbidity?

Objective.

To estimate incremental costs for patients with psoriasis/psoriatic arthritis (PsO/PsA) compared to population-based referents free from PsO/PsA and estimate costs attributable specifically to PsO/PsA.

Methods.

Patients were identified by International Classification of Diseases, 10th ed., codes for PsO/PsA using information from 1998 to 2007 in the Skåne Healthcare Register, covering healthcare use for the population of the Skåne region of Sweden. For each patient, 3 population-based referents were selected. Data were retrieved from Swedish registers on healthcare, drugs, and productivity loss. The human capital method was used to value productivity losses. Mean annual costs for 2008 to 2011 were assessed from a societal perspective.

Results.

We identified 15,283 patients fulfilling the inclusion criteria for PsO [n = 12,562, 50% women, mean age (SD) 52 (21) yrs] or PsA [n = 2721, 56% women, mean age 54 (16) yrs] and included 45,849 referents. Mean annual cost per patient with PsO/PsA was 55% higher compared to referents: €10,500 vs €6700. The cost was 97% higher for PsA compared to PsO. Costs due to productivity losses represented the largest share of total costs, ranging from 52% for PsO to 60% for PsA. Biological drug costs represented 10% of the costs for PsA and 1.6% for PsO. The proportion of cost identified as attributable to PsO/PsA problems was greatest among the patients with PsA (drug costs 71% and healthcare costs 31%).

Conclusion.

Annual mean incremental societal cost per patient was highest for PsA, mainly because of productivity losses and biological treatment. A minor fraction of the costs were identified as attributable to PsO/PsA specifically, indicating an increased morbidity in these patients that needs to be further investigated.

Disease Severity, Quality of Life, and Psychiatric Morbidity in Patients With Psoriasis With Reference to Sociodemographic, Lifestyle, and Clinical Variables: A Prospective, Cross-Sectional Study From Lahore, Pakistan

BACKGROUND

Psoriasis is an immune-mediated, chronic disease with a genetic background that involves skin, nails, and joints. The incidence of psoriasis varies from 2.0% to 4.0% depending on the geographical location, ethnic background, and environmental conditions. Recent research has proved that psoriasis is a systemic inflammatory disease with extensive systemic implications. Objectives of the study were to explore the severity of psoriasis, dermatology-related quality of life, and psychiatric health of the patients with reference to sociodemographic, lifestyle, and clinical characteristics.

METHOD

Consecutive patients with psoriasis (ICD-10 criteria) from skin outpatient clinics of 3 tertiary care hospitals in Lahore, Pakistan, between November 1, 2012, and December 31, 2012, were assessed in this prospective cross-sectional study. The final sample includes 87 patients who were evaluated for severity of psoriasis (Psoriasis Area Severity Index [PASI]), dermatology-related quality of life (Dermatology Life Quality Index [DLQI]), and psychiatric morbidity (12-item General Health Questionnaire [GHQ-12]) and were assessed on 23 sociodemographic, lifestyle, and clinical variables.

RESULTS

Of the 23 variables, the PASI was significantly associated with education and habit of drinking alcohol (P < .05), the DLQI was significantly associated with disturbed eating (P < .05), and the GHQ-12 score was significantly associated with hair disease (P < .05), current income (P < .05), and disturbed eating and sleeping (P < .01). The PASI, DLQI, and GHQ-12 were not usually affected by sociodemographic, lifestyle, and clinical factors, except for some variables such as education of the patient, alcohol intake, eating and sleeping disturbance, and income status. A statistically significant correlation (P < .01) was found between all 3 scores (ie, PASI, DLQI, and GHQ-12). The correlation coefficients of the PASI with the DLQI and GHQ-12 are 0.345 and 0.460, respectively, and that of the DLQI with the GHQ-12 is 0.635. A moderating effect of the DLQI score was found on the relationship between the PASI and GHQ-12 scores.

CONCLUSIONS

Psoriasis has an immense impact on the life of patients and common comorbidities in psoriasis including coronary heart disease, depression, cerebrovascular disease, and metabolic syndrome. Screening for these comorbidities in psoriasis patients is essential. Impaired quality of life negatively affects the psyche of patients and initiates coping mechanisms, which may lead to depression and anxiety, social dysfunction, and loss of confidence, and the psychosocial burden of the disease may become more than the physical burden. The dermatologist usually manages physical disease and fails to address the social, emotional, and psychological aspects. Quality of life improves if these psychological aspects are also properly dealt with.

Diagnosing and treating psoriatic arthritis: an update

Psoriatic arthritis (PsA) is an inflammatory arthritis of uncertain pathogenesis, affecting approximately one in four patients with psoriasis. Onset of psoriasis typically precedes the development of PsA. Therefore, the dermatologist is ideally positioned to recognize the early signs and symptoms of PsA for diagnosis and subsequent treatment. The role of the dermatologist in early diagnosis and treatment is essential for preventing pain and functional disabilities, as well as the joint deterioration that accompanies progressive forms of PsA. Diagnosis of PsA is a key aspect of the clinical decision process for the dermatologist, as psoriasis plus PsA requires a different therapeutic approach from that required for psoriasis alone. Furthermore, PsA is associated with an increased risk of cardiovascular comorbidities that present significant health concerns. In this review, the pathogenesis and comorbidities of PsA are discussed. In addition, screening and imaging tools that aid in the diagnosis of PsA, as well as tools used for efficacy assessment, are reviewed. Available therapies are presented, with a focus on targeted biologics and emerging treatments.

[Disease burden of psoriasis associated with psoriatic arthritis in Hungary]

INTRODUCTION

Psoriasis is a frequent, chronic, systemic immune-mediated disease mainly affecting the skin and joints.

AIM

To assess health related quality of life and cost-of-illness in moderate to severe psoriasis associated with psoriatic arthritis.

METHOD

A cross-sectional questionnaire survey was conducted at two academic dermatology clinics in Hungary.

RESULTS

Fifty-seven patients (65% males) completed the survey with a mean age of 54.3±11.6 years and mean EQ-5D score of 0.48±0.4. Mean annual total cost was €8,977 per patient, of which 71% occurred due to biological therapy and 21% were indirect costs, respectively. Permanent work disability due to psoriasis accounted for €1,775 (95% of the indirect costs). Per patient costs of subgroups not receiving systemic therapy (21%), traditional systemic therapy (32%), and biological systemic therapy (47%) amounted to the sum of €1,729, €1,799, and €16,983, respectively.

CONCLUSIONS

Patients on biological therapy showed significantly better health related quality of life. As for health economics, the efficacy of systemic treatments is appropriate to be assessed together in patients with moderate to severe psoriasis associated with psoriatic arthritis, since actual health gain might exceed that reported in psoriasis or psoriatic arthritis separately.

Targeting of interleukin-17 in the treatment of psoriasis

“Psoriasis” is a chronic immune-mediated inflammatory disorder with epidermal hyperplasia. There is some evidence that the cytokine interleukin-17A (often known as IL-17), which is mainly produced by Th17 cells, has a role in the pathogenesis of psoriasis. “IL-17” is a pro-inflammatory cytokine mainly important in the host’s defense against extracellular bacteria and fungi. The three new therapies with biologic drugs – brodalumab, secukinumab, and ixekizumab – all target the IL-17 signaling pathway. Secukinumab and ixekizumab neutralize IL-17A, while brodalumab blocks its receptor. Results from clinical trials have shown marked improvements in disease severity in patients with moderate-to-severe plaque psoriasis, using any of these three drugs. The biologic agents were generally well tolerated, but the duration of the trials was relatively short. In this review, we focus on the role of the IL-17 cytokine family in the pathogenesis of psoriasis; the efficacy, safety, and tolerability of brodalumab, secukinumab, and ixekizumab in clinical trials; and possible differences between targeting of the IL-17A receptor and targeting of the IL-17A ligand.

Psychological differences between early- and late-onset psoriasis: a study of personality traits, anxiety and depression in psoriasis

BACKGROUND

Onset of psoriasis may occur at any age. Early negative experiences often influence personality development, and may lead to physical disease, anxiety and depression in adulthood. Knowledge about onset of psoriasis and psychopathology is limited.

OBJECTIVES

To examine whether patients with early-onset psoriasis differ psychologically from patients with late-onset psoriasis, regarding personality traits, anxiety and depression.

METHODS

A descriptive cross-sectional study was conducted among 101 consecutively recruited outpatients with psoriasis. A psychosocial interview was performed followed by self-assessment of validated questionnaires: Swedish Universities Scales of Personality (SSP), Spielberger State-Trait Anxiety Inventory and Beck Depression Inventory. Psoriasis severity was assessed by the Psoriasis Area and Severity Index.

RESULTS

Patients with early-onset psoriasis (age < 20 years) were significantly more anxious and depressed than patients with late-onset psoriasis. In multiple linear regression models, younger age at onset of psoriasis was a significant determinant of higher scores of four personality traits: SSP-embitterment, -trait irritability, -mistrust and -verbal trait aggression.

CONCLUSIONS

Our results indicate that early detection of psychological vulnerability when treating children and adolescents with psoriasis seems to be of great importance. Traits of psychological vulnerability and pessimistic personality traits were found to be significantly associated with the early onset of psoriasis, but not with disease duration in this study. These traits may be seen as a consequence of psoriasis, and/or as individual traits modulating and impairing clinical course and efforts to cope with psoriasis.

Hope as a Psychological Factor Affecting Quality of Life in Patients With Psoriasis

Clinical observations and medical reports indicate that psoriasis has a tremendous impact on patients' lives, lowering their quality in many important areas. However, the vast majority of research deals only with health-related issues. This study aimed to compare the general quality of life of psoriasis patients and healthy volunteers by examining psychological variables thought to modify the quality of life. 42 patients with psoriasis and 42 healthy volunteers matched for gender, age and education level were tested. Flanagan Quality of Life Scale was used to evaluate general quality of life. Basic hope level was assessed with Basic Hope Inventory. Trait hope was estimated using Trait Hope Scale. Psoriasis Area Severity Index was used to assess the severity of the disease. Psoriasis patients have a significantly lower overall quality of life (p = 0.05), modified by Physical and Material Well-being (p = 0.01), Personal Development and Fulfillment (p = 0.03), and Recreation (p = 0.04). They also have lower levels of trait hope (p = 0.04) and its agency component (p = 0.01). There were moderate, negative significant correlations with basic hope and such components of quality of life as Physical and Material Well-being (p = 0.03, r = - 0.34) and Relations with other People (p = 0.02, r = - 0.35). These results support the hypothesis of a reduced general quality of life and trait hope in psoriatics. Thus, psychological help for people suffering from dermatological disorders might be as important as medical intervention. Basic hope can be treated as a resource in coping with these disorders and trait hope as a resource conducive to well-being.

The burden of moderate to severe psoriasis: an overview

Psoriasis is a chronic, immune-mediated skin disorder that affects 1-3% of the general population worldwide. While considered a non-life-threatening disease, psoriasis represents a social and financial burden for patients and the healthcare system. Individuals suffer from disfigurement and from social stigmatization. Because the disease is usually persistent, patients with a diagnosis of psoriasis usually need lifelong care, which also means a lifetime of expenses. We aimed to conduct a comprehensive review of the evidence available concerning the social burden and costs of psoriasis. A search for the keywords 'quality of life' (QOL) or 'burden' or 'stigmatization' or 'psychological factors' in PubMed up to January 2010 yielded a total of 817 studies. QOL was affected by psoriasis to a degree comparable with diabetes or cancer. A search for 'cost-of-illness analyses', in the same period, yielded only seven papers satisfying entry criteria. All the studies but one were performed before biologics became available for psoriasis treatment. Direct costs were higher than indirect costs, with hospitalization representing the most significant item. Treatment costs showed wide variations between different studies. Reasons for these discrepancies are manifold including differences in the selection of the sample, as well as in the methods for calculating costs. There is a need to harmonize methodologies. For a final conclusive judgement of the cost effectiveness of innovative therapies such as biological agents, long-term economic consequences have to be evaluated and long-term remission rates and complications considered.

Impaired quality of life in adults and children with scabies from an impoverished community in Brazil

BACKGROUND

Scabies is highly prevalent in resource-poor communities in developing countries and is associated with considerable morbidity in this setting. How the parasitic skin disease impairs the quality of life of patients has rarely been investigated.

METHODOLOGY

A modified Dermatology Life Quality Index (mDLQI) was developed to assess the quality of life in adults and children with scabies living in an urban slum in Fortaleza, capital of Ceará State, Brazil. A total of 105 patients with scabies (58 children and 57 adults) were included in the study. The diagnosis was made by dermatoscopy, skin scraping, and adhesive film test.

RESULTS

Feelings of shame was the restriction most frequently noted (adults 77.2% and children 46.6%). Other types of quality of life impairment were the need to dress differently (35.1 vs. 29.3%), restriction on leisure activities (24.6 vs. 36.8%), social exclusion (24.6 vs. 17.9%), stigmatization (21.1 vs. 25.0%), teasing (only children: 26.3%), and problems with sexual partners (only adults: 10.9%). Women and girls perceived more restrictions than men and boys. mDLQI scores indicated that 13.9% of the patients noticed a large or very large effect on their life, 65.2% considered their quality of life lightly or moderately reduced by scabies, and 20.9% did not feel any restrictions. The degree of impairment increased parallel to the degree of itching and severity of scabies (P=0.003).

LIMITATIONS

Owing to active case finding, most of the patients were in an early phase of scabies, and clinical pathology was not very pronounced.

CONCLUSION

Scabies considerably impaired the quality of life in adults and children living in poverty in an urban slum. Females particularly suffered from restrictions.

Management of psoriasis in Africa and the Middle East: a review of current opinion, practice and opportunities for improvement

Psoriasis is a common, chronic, systemic, inflammatory disease of the skin that is often associated with inflammatory musculoskeletal disease. Psoriasis impacts on affected individuals and on society at many levels, being associated with considerable economic burden and impaired quality of life. This article aims to provide dermatologists and their allied healthcare professionals, particularly those practicing in Africa and the Middle East, with a review of the current understanding of psoriasis, its treatment and impact, as a backdrop for further discussion of the management of psoriasis in these regions. Insight into the real-life, day-to-day challenges and unmet needs currently facing dermatologists in Africa and the Middle East is provided by the authors, most of whom are experienced dermatologists practicing in this region.

Management of psoriatic arthritis from the view of the dermatologist

Psoriatic arthritis (PsA) is an inflammatory seronegative spondyloarthropathy associated with psoriasis. Although the main assessment measures for PsA are borrowed from the standard criteria used to assess rheumatoid arthritis, a number of new criteria such as the PsAJAI and CPDAI are being developed specifically for PsA. Long-term consequences of untreated PsA include persistent inflammation, progressive joint damage and, in many cases, substantial functional limitations, pain and disability. Moreover, patients with PsA have an increased mortality risk and an increased risk of developing cardiovascular disease and metabolic syndrome. Both GRAPPA and the AAD have developed treatment guidelines, which are discussed here. Psoriasis commonly precedes arthritic symptoms; thus, dermatologists are ideally placed to make the initial diagnosis of PsA and treat it appropriately, affording the opportunity to slow disease progression, improve physical function and enhance quality of life. This Review explores the management of patients with PsA, with a particular emphasis on assessment tools, long-term consequences and treatment issues from the viewpoint of the dermatologist.

Dipeptidyl peptidase IV (DPP4) deficiency increases Th1-driven allergic contact dermatitis

BACKGROUND

CD26 or dipeptidyl peptidase IV (DPP4) is known to be involved in several immunological processes and has recently been reported to play a crucial role in the allergic responses of the lungs.

OBJECTIVES

To explore the impact of DPP4 on the allergic response of the skin.

METHODS

Skin biopsies from patients suffering from atopic dermatitis (AD) and healthy controls were investigated for the expression of CD26/DPP4. Furthermore, the functional impact of CD26 was investigated in two models of contact hypersensitivity using CD26/DPP4-deficient and wild-type rats. Dinitrochlorobenzene (DNCB) was used to induce a T helper type 1 (Th1)-dominated inflammation and toluene-2,3-diisocyanate for a Th2-pronounced inflammation. The inflammatory responses were determined by histological quantification, flow cytometry [fluorescence-activated cell sorting (FACS)], and an enzyme-linked immunosorbant assay (ELISA).

RESULTS

CD26/DPP4-expression was up-regulated in the lesional skin biopsies of patients compared with healthy controls as well as in both models of contact hypersensitivity. However, in the more Th2-driven model, a reduced inflammatory skin response was found in CD26/DPP4-deficient rats, analogous to the effects observed recently in a rat model of asthma. In partial contrast, there was an aggravation of local skin inflammation in CD26/DPP4-deficient rats under conditions of Th1-like skin inflammation.

CONCLUSION AND CLINICAL RELEVANCE

The up-regulation of CD26 in atopic dermatitis represents a new finding, which has also been seen in other inflammatory skin diseases. However, tissue expression of CD26/DPP4 in immunological skin response can either be beneficial or aggravating, depending on a possible Th1/Th2 shift. This might have consequences for humans suffering from diabetes mellitus treated by DPP4 inhibitors, who have eczematous skin diseases as a co-morbidity.

Potential role of ustekinumab in the treatment of chronic plaque psoriasis

Psoriasis is a relatively common, chronic and disabling skin disease, with an immune-related pathogenesis and a genetic background which may be triggered by several environmental factors including smoking and infections. There is no cure but several treatment options are available. The treatment of psoriasis is far from being satisfactory due to impractical modalities of topical treatment and suboptimal safety profile of the systemic treatments available. In the last few years, parallel to an improved understanding of the disease pathogenesis, there has been a boost in research on new agents for the treatment of psoriasis. Ustekinumab, a monoclonal antibody targeting the p40 subunit of interleukin (IL)-12 and IL-23, is one such new agent. Psoriasis and its management are briefly reviewed before focusing on the evidence for ustekinumab in the treatment of chronic plaque psoriasis through a systematic search of the main registries of ongoing trials up to December 2009. Ustekinumab proved to be very effective short term in the control of clinical manifestations in psoriasis compared with placebo and with etanercept. Long-term and comparative data are still limited. There is a need for continuing research on the long-term effectiveness and safety of the drug.