Assessing the Impact of Psoriasis and the Relevance of Qualitative Research

How important is subjective well-being for patients? A qualitative interview study of people with psoriasis

PURPOSE

This qualitative study aimed to investigate the importance of subjective well-being (SWB) as an outcome of psoriasis treatment from patient's perspective. We focused on the affective component of SWB as assessed with the Daily Experience Sampling Questionnaire (DESQ), a validated daily diary.

METHODS

Semi-structured qualitative telephone interviews were conducted with in-patients of a dermatological rehabilitation clinic, after participants had completed the DESQ for up to seven days to get familiar with the concept of SWB. Patients were asked to reflect on the importance of SWB as treatment goal and on its relative importance as compared with other treatment outcomes. We also addressed whether SWB could be an indirect measure of benefit in that it reflects other important outcomes. Transcripts were analyzed using content analysis.

RESULTS

Eleven patients participated (24-63 years, mean 53 years, 8 male, 3 female). Participants uniformly confirmed that changes in SWB reflected treatment benefit. All but one considered SWB to be a central aspect of treatment benefit-either as the most important treatment goal or as an indirect benefit indicator. In particular, participants described positive associations of SWB with other outcomes, such as symptoms. They reported that both the disease and the medical treatment had an impact on their SWB, which was reflected in the DESQ.

CONCLUSION

Our findings suggest that SWB is a relevant indicator of treatment benefit for patients with psoriasis. Therefore, SWB measures, such as the DESQ, could be used to operationalize patient-relevant benefit of psoriasis treatment, complementing outcome measures currently used.

Research Techniques Made Simple: An Introduction to Qualitative Research

Qualitative research has gained increasing prominence in health-related research and is experiencing greater use in dermatology. A major strength of and reason to perform qualitative research is that it allows one to gain an understanding of the insider (e.g., patient, medical provider, other players in the healthcare system) perspectives on health and insights about their behaviors, motivations, and expectations. This is particularly important in the field of dermatology where most diseases are, fortunately, not directly fatal but have major effects on affected individuals' lives in ways that are often not readily quantifiable. As such, it is important for dermatologists, both researchers and clinicians, to understand the basic tenets of qualitative methodology to properly utilize qualitative methods, evaluate the qualitative literature, and identify relevant findings to apply to clinical practice. In this article, we provide an overview of qualitative research and some of the more commonly used qualitative methods with an aim to increase awareness and appreciation of the power of qualitative studies.

Dermatological diseases, sexuality and intimate relationships: A qualitative meta-synthesis

AIMS AND OBJECTIVES

To conduct a systematic review and meta-synthesis of findings from qualitative research about sexuality and intimate relationship among patients with dermatological diseases.

BACKGROUND

Over the last few decades, there has been an increase in clinical research investigating aspects related to sex and sexuality in patients living with dermatological diseases. In fact, studies recognise a negative impact on various aspects of intimacy, such as sexual function, self-esteem and romantic relationships. The body of qualitative literature about sexuality in the context of dermatological diseases is emerging but consists mainly of small studies that would benefit from aggregation, synthesis and interpretation to highlight and summarise the overarching dimensions to this clinical issue.

DESIGN

A systematic review and meta-synthesis of qualitative studies.

METHODS

BioMed Central, Cochrane Library, MEDLINE, CINAHL, PsycINFO, PsycARTICLES, ERIC, Scopus, and Web of Science were searched between June-November 2017 with no publication date limits. Screening and selection of studies was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA). After retrieval, the qualitative data were subject to meta-synthesis to identify overarching themes.

RESULTS

Ten qualitative studies were found. We identified four themes: (a) Embarrassment and shame; (b) Impaired sense of attractiveness and sexual avoidance; (c) Relationship issues; and (d) Lack of professional support. The patients in these studies adopted negative coping styles, such as avoidance and hiding their bodies.

CONCLUSION

When assessing and evaluating patient care in dermatology, it is important that sexuality and the impact the disease could have on relationships is included.

RELEVANCE TO CLINICAL PRACTICE

An important part of nursing care is ensuring that patients are helped to develop positive coping strategies rather than negative ones. Patients with dermatological conditions also need advice and treatment to address any physically related sexual problems. Nurses need to be the initiators of these sensitive conversations to put patients at ease and work together to implement positive measures to reduce the sexuality-related issues patients face.

Patients' Perspectives on the Impact of Genital Psoriasis: A Qualitative Study

Introduction

Plaque psoriasis is a chronic skin disease where genital involvement is relatively common. Yet health care providers do not routinely evaluate psoriasis patients for genital involvement and patients do not readily initiate discussion of it.

Methods

A qualitative study of 20 US patients with dermatologist-confirmed genital psoriasis (GenPs) and self-reported moderate-to-severe GenPs at screening was conducted to identify key GenPs symptoms and their impacts on health-related quality of life (HRQoL).

Results

Patients had a mean age of 45 years, 55% were female, and patients had high rates of current/recent moderate-to-severe overall (65%) and genital (70%) psoriasis. Patients reported the following GenPs symptoms: genital itch (100%), discomfort (100%), redness (95%), stinging/burning (95%), pain (85%), and scaling (75%). Genital itching (40%) and stinging/burning (40%) were the most bothersome symptoms. Impacts on sexual health included impaired sexual experience during sexual activity (80%), worsening of symptoms after sexual activity (80%), decreased frequency of sexual activity (80%), avoidance of sexual relationships (75%), and reduced sexual desire (55%). Negative effects on sexual experience encompassed physical effects such as mechanical friction, cracking, and pain as well as psychosocial effects such as embarrassment and feeling stigmatized. Males reported a higher burden of symptoms and sexual impacts. Other HRQoL impacts were on mood/emotion (95%), physical activities (70%), daily activities (60%), and relationships with friends and family (45%). These impacts significantly affected daily activities. Physical activities were affected by symptoms and flares, and increased sweat and friction worsened symptoms. Patients reported daily practices to control outcomes.

Conclusion

The high level of reported symptoms and sexual and nonsexual impacts reflects the potential burden of moderate-to-severe GenPs. GenPs can impact many facets of HRQoL and providers should evaluate their patients for the presence of genital psoriasis and its impact on their quality of life.

Funding

Eli Lilly and Company.

Electronic supplementary material

The online version of this article (doi:10.1007/s13555-017-0204-3) contains supplementary material, which is available to authorized users.

Background

Psoriasis is a skin disease that can cause itchy, raised red patches of skin. Currently, psoriasis cannot be cured but medicines can make the patches smaller or go away completely. The patches can occur anywhere on the body. Sometimes people get them in their genital area. However, people are sensitive about this area and may not tell their doctor. Their doctor may not look or ask either.

What We Did

We interviewed 20 men and women who had moderate-to-severe genital psoriasis. We asked about their health-related quality of life, including their sex life.

What We Learned

All 20 people said they had symptoms of itching and discomfort in their genital area. Most people also had symptoms of redness, stinging or burning, pain, and scaling (flaky skin). Most people said symptoms affected their sex life. Sexual activity was less comfortable. People had sexual activity less often. Physical reasons, such as pain, bothered some people. Emotional reasons, such as being embarrassed, bothered other people more. People said the genital psoriasis affected how they felt. For example, it made them stressed, angry, or sad. Genital psoriasis made physical activities such as walking and running more uncomfortable for many people, especially when symptoms “acted up.” Sweating a lot, wearing tight underwear, or working a long day could make symptoms worse too. About half the people spent less time with their family and friends because of their symptoms. People also did things to try to reduce their symptoms. Some people wore loose clothes or soaked in a bathtub every night or after sex. Other people carried cream (to stop the itch) with them all the time.

Conclusion

Other people may not experience what these 20 people did. However, having genital psoriasis can significantly impact someone’s life. Patients and doctors should talk about it.

Electronic supplementary material

The online version of this article (doi:10.1007/s13555-017-0204-3) contains supplementary material, which is available to authorized users.

Severity and management of psoriasis within primary care

BACKGROUND

Scottish Intercollegiate Guidelines Network and National Institute of Health and Care Excellence guidelines stress the importance of assessing patients with psoriasis for psoriatic arthritis, comorbidities associated with severe disease and quality of life (QoL). The purpose of the study was to evaluate the primary care management of psoriasis in relation to disease severity and QoL from a patient's perspective.

METHODS

A cross-sectional survey of adults (≥18 years) with psoriasis managed in primary care was conducted in Scotland over 1-year (2012-2013). Patients with psoriasis were identified and invited to participate in the online/telephone survey. The questionnaires included; Dermatology Life Quality Index (DLQI), Self-Administered Psoriasis Area and Severity Index (SAPASI), Psoriasis Epidemiology Screening Tool (PEST). The primary outcome measure was DLQI. Secondary outcomes included; demographics; comorbidities; involvement of different body sites; SAPASI and PEST scores. Relationships between measures were analysed using univariate analysis.

RESULTS

The mean age of patients (n = 905) was 54.5 years (SD = 16.1), 436 (48.2 %) were men, and median DLQI and SAPASI scores were 4.0 and 6.0, respectively. Current psoriasis treatments were topical only (587, 64.9 %), oral medications or phototherapy (122, 13.5 %), biologics (26, 3 %) and none (156, 17.2 %). Despite SIGN recommendations, 256 of 391 patients (65.5 %) with a DLQI >5 (at least a moderate effect on QoL) had not seen a specialist during the past year. According to PEST scores, 259 patients (28.6 %) had symptoms suggestive of psoriatic arthritis requiring rheumatology referral.

CONCLUSION

National recommendations are not being fully implemented in primary care in patients with psoriasis or psoriatic arthritis.

Moderate to severe psoriasis patients' subjective future expectations regarding health-related quality of life and longevity

BACKGROUND

Unrealistic expectations regarding treatments and clinical outcomes may lead to disappointment about therapy and sub-optimal compliance; nonetheless, these expectations have not been studied in psoriasis patients yet.

OBJECTIVE

To evaluate psoriasis patients' subjective future expectations regarding health-related quality of life (HRQOL) and life expectancy, and to explore clinical features associated with under- or overestimating behaviour.

METHODS

A cross-sectional questionnaire survey of consecutive adult patients with moderate to severe psoriasis was conducted. HRQOL expectations were recorded by applying the EQ-5D descriptive system for 6 months ahead and for future ages of 60, 70, 80 and 90 respectively.

RESULTS

In total, 167 patients (71% males) were included in the analysis with mean age of 50.4 ± 12.4 years and mean EQ-5D score of 0.71 ± 0.30. Overall 65% had chronic plaque psoriasis, 35% nail psoriasis, 35% scalp involvement, 29% psoriatic arthritis, 9% inverse psoriasis and 5% palmoplantar psoriasis respectively (combinations occurred). Participants expected 0.1 ± 0.23 mean improvement in EQ-5D within 6 months (P < 0.001) that achieves the minimum clinically important difference. Overall 37% expected improvement and 13% decline; however, 49% expected no changes in any of the five dimensions of EQ-5D within 6 months. Female gender, inverse or palmoplantar involvement and more severe psoriasis were likely associated with higher expectations. Patients at the initiation of their first biological at the time of the survey expected 0.18 ± 0.24 increase that seems to be realistic compared to the EQ-5D utility gain achieved in randomized controlled trials. Males expected by 2.7 ± 11.1 more, while females expected by 5.2 ± 9.3 less life years compared to the average statistical gender- and age-matched life expectancy (P < 0.05). Patients who expected to be alive at ages of 60, 70, 80 and 90 scored their future EQ-5D at ages of 60 to 90: 0.59 ± 0.46, 0.48 ± 0.41, 0.42 ± 0.41 and 0.22 ± 0.47 respectively.

CONCLUSION

Our findings highlight the importance of exploring expectations that might help to increase patients' compliance.

Identifying individual psychosocial and adherence support needs in patients with psoriasis: a multinational two-stage qualitative and quantitative study

BACKGROUND

Psoriasis has a serious impact on patients' lives. However, adherence to medications is often poor, potentially compounding the burden of disease. Identifying patients who need support with psychosocial problems, or issues with adherence, can be complex.

OBJECTIVES

We aimed to develop statements that could assist the consultation process, identifying the relative importance of factors related to effective management of psoriasis for patients.

METHODS

A two-stage study design was used to comprehensively identify, and assess validity of, statements describing psoriasis impact and management issues. Both components were conducted in Canada, France, Germany, Italy, Spain, the United Kingdom and the United States. Findings from patient observation and interviews were analysed for pattern strength, and were then used to inform the development of statements that were quantitatively assessed using a survey. The association of drivers towards agreement with 'my psoriasis dictates how I lead my life' was assessed using anova.

RESULTS

Fifty-six patients participated in the qualitative component, and 1,884 patients using prescription medications completed the survey. Two thematic categories were identified; disappointment with treatments, and confusion regarding psoriasis associated with a lack of direction. When assessed quantitatively, key statements associated with a strong burden of psoriasis on patients' lives were related to isolation, social stigma, visible symptoms, impact on activities and feelings of hopelessness. A mixture of patient-, doctor- and treatment-related factors were among the most common reasons for non-adherence.

CONCLUSION

Questioning using the statements most associated with psychosocial impact and non-adherence could help identify patients with additional support needs, and assist in overcoming adherence issues.

Recognition of need in health care consultations: a qualitative study of people with psoriasis

BACKGROUND

Psoriasis is a life-long inflammatory condition that can impact on quality of life, psychological and social functioning. Previous literature suggests patient dissatisfaction with psoriasis management; however, little is known about people's specific experiences of health care consultations.

OBJECTIVES

The study aimed to explore in depth the perspectives of people living with psoriasis including coping responses, self-care strategies and how consultations with health care professionals in both primary and secondary care are experienced.

METHODS

Qualitative semistructured interviews were carried out with a diverse sample of 29 people with psoriasis generated purposively and recruited from community sources in North West England. Interviews were coded using Framework Analysis to produce a thematic framework incorporating key emerging issues and concepts.

RESULTS

Participants experienced psoriasis as a complex condition involving physical, psychological and social challenges, as well as issues of control, but perceived that these were largely unacknowledged by practitioners in health care consultations. Practitioners were perceived as lacking knowledge and expertise in the management of psoriasis, lacking empathy with the effects of psoriasis and failing to manage it as a long-term condition. This perceived lack of support resulted in some participants withdrawing from conventional health service providers and seeking alternative sources of help.

CONCLUSIONS

Psoriasis needs to be recognized and managed as a complex long-term condition with emotional and social needs that are addressed alongside appropriate diagnosis and regular reviews of treatments which may involve referrals to specialist care.

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.

Clinical improvement in psoriasis with treatment of associated hyperlipidemia

Psoriasis is associated with an increased risk of cardiovascular disease, a principal cause of which is atherosclerosis caused by hyperlipidemia. However, it is not known whether treatment of hyperlipidemia in patients with psoriasis lead to clinical improvement in psoriasis condition. In this study, the authors summarize the existing literature relevant to this inquiry. They also describe the potential pathways believed to link psoriasis with atherosclerosis and the role of hyperlipidemia therapy in this setting. A few studies indicated clinical improvement in psoriasis with treatment of associated hyperlipidemia. Some studies showed that a low-fat diet improved psoriasis. Others indicated a decreased risk of psoriasis associated with intake of cholesterol-lowering drugs such as "statins." Treatment with statins increased lactate dehydrogenase level and diminished Psoriasis Area and Severity Index score, ie, reduced cutaneous lesion in psoriasis. Beneficial effects of statin therapy on psoriasis included downregulation of lymphocyte function-associated antigen-1, inhibition of leukocyte endothelial adhesion, extravasation and natural killer cell activity, inhibition of proinflammatory cytokines such as tumor necrosis factor-alpha and interleukin 1 and 6, lowering of C-reactive protein, promotion of a T(H)1 to T(H)2 cells and inhibition of T(H)1 cytokine receptors on T cells, leading to inhibition of activation of lymphocytes and infiltration into the inflammation sites. Taken together, current literature indicates clinical improvement in psoriasis condition with treatment of associated hyperlipidemia, particularly with statins of which the mechanisms could be attributed to immunomodulatory and anti-inflammatory effects.

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.

Visible skin condition and perception of human facial appearance

Evolutionary psychology suggests that certain human beauty standards have evolved to provide reliable cues of fertility and health. Hence, preferences for some physical characteristics of the face and body are thought to reflect adaptations for the promotion of mate choice. Studies that have investigated facial attractiveness have concentrated mainly on features such as symmetry, averageness and sex-typical traits, which are developed under the influence of sex steroids. Few studies, however, have addressed the effect of human skin condition on perception of facial appearance in this context, and possible implications for sexual selection. There is now accumulating evidence that skin pigmentation and skin surface topography cues, particularly in women, have a significant influence on attractiveness judgements, as they seem primarily to signal aspects of age and health. This article (i) reviews briefly some of the main determinants of visible skin condition, (ii) presents recent evidence on its signalling value in face perception and (iii) suggests areas for future research with reference to an evolutionary psychology framework.

Emerging drugs for psoriasis

BACKGROUND

Psoriasis is a relatively common, chronic and disabling skin disease, due to a disturbed proliferation and differentiation of keratinocytes, accompanied by vascular alterations and infiltration of inflammatory cells with a local T(H)1-type cytokine immune response. There is no cure, but several treatment options are available.

OBJECTIVE

The treatment of psoriasis is far from being satisfactory, due to the impractical modalities of topical treatment and the 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 boosting of research in new agents for the treatment of psoriasis. These new agents are the focus of this paper.

METHODS

After a short review of the treatment options already available (mainly based on the available systematic reviews), we focused on agents that are still in clinical development (Phase I - III) and have not yet entered the market. For the purpose of this study, we systematically searched the main registries of ongoing trials up to August 2008.

RESULTS/CONCLUSION

The field is very dynamic, with both immunopharmacology of recombinant DNA techniques and more traditional small-molecule pharmacology actively delivering new agents. With the increasing number of new options, there is a need for research systems that enable to effectively collect long-term safety data on treated patients.

Patients' views on care and treatment after phototherapy for psoriasis and atopic eczema including a gender perspective

BACKGROUND

Psoriasis and atopic eczema are reportedly as common among women as among men and are not known to differ in severity between sexes. Research has shown that men get more treatment with ultraviolet (UV) light for longer periods than women. This fact, together with ongoing efforts to improve patient satisfaction with care and treatment at our department, prompted us to gather information from our patients.

OBJECTIVE

The aim of this study was to explore patients' views of dermatological care and treatment methods.

METHOD

A questionnaire-based survey was carried out, complemented with qualitative interviews.

RESULTS

The main findings fall under three areas of clinical relevance: information to patients must be individually designed with a gender perspective; men and women have different attitudes towards greasing which must be kept in mind in clinical practice; and women often appear to be under-prescribed UV treatment.

CONCLUSION

The information from our study can form a basis for new therapeutic strategies, taking a gender perspective into account.

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

Negative impact of psoriasis and psoriasis arthritis on quality of life is a central consequence of these diseases. Feelings of stigmatization might, for example, already emerge with only small patches of skin being affected. Empirical data indicate that treating dermatologists should address possible negative effects elicited by problematic encounters with the public and in sexual relationships even if the severity of the disease is low, because lesions on invisible parts of the body can already cause serious adverse impairment. Such psychosocial consequences can be reduced by attending a self-help organization and by taking part in an interdisciplinary patient education program led by dermatologists.