What criteria do patients use when judging the effectiveness of psoriasis management?

Pellino-1 expression is associated with epidermal proliferation and enhanced Th17 cell infiltration in psoriatic lesions

Pellino-1 plays a crucial role in cellular proliferation and regulates inflammatory processes. This study investigated Pellino-1 expression patterns and their relationship with CD4+ T-cell subsets in psoriasis patients. Group 1 comprised primarily biopsied psoriasis lesions from 378 patients, multiplex-immunostained for Pellino-1, CD4 and representative T helper (Th) cells (T-bet [Th1], GATA3 [Th2], and RORγt [Th17] and regulatory T cell [FoxP3] markers). Ki-67 labeling was evaluated in the epidermis. Group 2 comprised 43 Pellino-1-positive cases immunostained for Pellino-1 in both lesion and non-lesion skin biopsy samples. Five normal skin biopsies served as controls. Among 378 psoriasis cases, 293 (77.5%) were positive for Pellino-1 in the epidermis. Pellino-1-positivity was higher in psoriasis lesions than in non-lesions and normal skin (52.55% vs. 40.43% vs. 3.48%, p < 0.001; H-score, 72.08 vs. 47.55 vs. 4.40, p < 0.001, respectively). Pellino-1-positive cases also had a significantly higher Ki-67 labeling index (p < 0.001). Epidermal Pellino1-positivity was significantly associated with higher RORγt+ (p = 0.001) and FoxP3+ (p < 0.001) CD4+ T cell ratios but not T-bet+ and GATA3+ CD4+ T cell ratios. Among the CD4+ Pellino-1+ T-cell subsets, the CD4+ Pellino-1+ RORγt+ ratio was significantly associated with epidermal Pellinio-1 expression (p < 0.001). Pellino-1 expression is thus increased in psoriasis lesions and associated with increased epidermal proliferation and CD4+ T-cell subset infiltration, especially Th17 cells. This suggests that Pellino-1 could be a therapeutic target that simultaneously regulates psoriasis epidermal proliferation and immune interactions.

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.

Treatment Goals for Psoriasis as Measured by Patient Benefit Index: Results of a National Psoriasis Foundation Survey

INTRODUCTION

This cross-sectional survey was conducted with National Psoriasis Foundation (NPF) to capture treatment perspectives and expectations in patients with psoriasis (PsO) using Patient Needs Questionnaire (PNQ) of Patient Benefit Index (PBI).

METHODS

Adult participants with self-reported diagnosis of PsO responded to the PNQ portion of PBI by indicating how much they valued different treatment attributes. All the treatment goals were captured on a five-point Likert scale (0 = "Not important", 4 = "Very important"). Treatment goals were obtained for overall population and subgroups based on severity of disease Patient Global Assessment (PGA), age, gender, and Dermatology Life Quality Index (DLQI) total score. All data were expressed as mean and standard deviation [SD].

RESULTS

A total of 1200 participants completed the survey (mean age 51.5 years). Top treatment goal in the overall population was "to have confidence in the therapy" (3.46 [1.01]). Unique to the higher severity subgroup (PGA ≥ 3), "to find a clear diagnosis and therapy" was a top five goal and "to get better skin quickly" was for those with lesser severity (PGA < 3). "To be free of itching" (3.36 [0.99]) was the unique goal in the < 40 age group whereas it was "to get better skin quickly" (3.27 [1.12]) in the ≥ 40 group. In women and men, "to be free of itching" (3.38 [1.13]) and "to get better skin quickly" (3.20 [1.09]) were top five goals, respectively. Patients with ≥ 10 DLQI scores expressed higher treatment goal "to regain control of the disease" (3.66 [0.67]) compared to those with ≤ 10 DLQI scores who expressed "to have confidence in the therapy" (3.40 [1.11]) as the topmost treatment goal.

CONCLUSION

Our results suggest that in patients with PsO, treatment preferences can vary with different characteristics such as age, severity, and gender as measured by using PNQ. Further exploration of this data will help inform treatment decisions and optimize patient outcomes.

Association Between the Mental Health of Patients With Psoriasis and Their Satisfaction With Physicians

Importance

How patients' mental health is associated with their satisfaction with physicians is rarely studied among adults with skin conditions.

Objective

To examine the association between mental health comorbidities in patients with psoriasis and their satisfaction with physicians.

Design, Setting, and Participants

This retrospective survey analysis used 14 years of nationally representative longitudinal data on adults in the United States with psoriasis from the 2004-2017 Medical Expenditure Panel Survey. Statistical analysis was performed from October 1, 2018, to December 1, 2019. Mental health comorbidities were measured by performance on the Kessler 6-Item Psychological Distress Scale (score range, 0-24, where a score ≥13 is considered an indicator of a serious mental illness and significant psychological distress) and the Patient Health Questionnaire 2 (score range, 0-6, where a score ≥3 is considered a positive screening result for a depressive disorder).

Main Outcomes and Measures

Patient satisfaction with physician, measured by the patient-physician communication composite score.

Results

A weighted total of 8 876 767 US adults with psoriasis (unweighted total, 652 patients) (weighted; 54% women; mean [SEM] age, 52.1 [0.7] years) were analyzed; 27% of adults had moderate or severe symptoms of psychological distress, and 21% had moderate or severe symptoms of depression. Patients with moderate or severe psychological distress symptoms were less satisfied with their clinicians compared with those with no or mild psychological distress symptoms (mean Kessler 6-Item Psychological Distress Scale scores for no or mild symptoms, 14.3 [95% CI, 14.2-14.4]; moderate symptoms, 13.2 [95% CI, 13.0-13.4]; and severe symptoms, 13.1 [95% CI, 12.5-13.7]; P < .001). In addition, compared with patients with no or mild psychological distress symptoms, patients with moderate psychological distress symptoms were 2.8 times more likely to report low patient satisfaction (adjusted odds ratio, 2.8 [95% CI, 1.5-4.9]; P = .001), and patients with severe psychological distress symptoms were 2.3 times more likely to report low patient satisfaction (adjusted odds ratio, 2.3 [95% CI, 1.1-4.7]; P = .03). Furthermore, patients with moderate or severe depression symptoms were less satisfied with their clinicians compared with those with no or mild depression symptoms (mean Patient Health Questionnaire 2 scores for no or mild symptoms, 14.3 [95% CI, 14.2-14.4]; moderate symptoms, 13.2 [95% CI, 12.9-13.6]; and severe symptoms, 13.0 [95% CI, 12.6-13.4]; P = .002). In addition, compared with patients with no or mild depression symptoms, patients with moderate depression symptoms were 4.6 times more likely to report low patient satisfaction (adjusted odds ratio, 4.6 [95% CI, 2.1-10.0]; P < .001).

Conclusions and Relevance

This study suggests that patients with greater psychological distress and depression report lower satisfaction with their clinicians than those without such mental health symptoms. Clinicians need to be adaptable and supportive when communicating with patients with mental health comorbidities. Evaluating clinician performance solely based on patient satisfaction can be problematic and incomplete.

Using qualitative methods to understand factors contributing to patient satisfaction among dermatology patients: a systematic review

PURPOSE

In this systematic review, we aimed to synthesize data that identify factors contributing to patient satisfaction in dermatology care using qualitative methods.

MATERIALS AND METHODS

We performed a comprehensive search of the literature using the PubMed database for articles published between January 1, 2000 and February 9, 2015. The initial search yielded 186 articles, of which 13 were included after applying inclusion and exclusion criteria.

RESULTS

The systematic review of 13 articles included a total of 330 patients. Using in-field observations and semistructured interviews, studies found that qualitative methods and analysis increased the provider's sensitivity to patient needs and enhanced patient care. Analyses using qualitative methods found increased patient satisfaction in their healthcare provider is associated with (1) confidence in the provider's diagnosis, (2) perception of patient-centered, individualized recommendations and (3) quality of patient education and provider explanation during a visit.

CONCLUSIONS

Patient satisfaction is measured using either quantitative or qualitative methods. Quantitative methods result in standardized data that often does not capture the nuances of patient experience. In contrast, qualitative methodology is integral to gathering patient perspectives on patient care and satisfaction and should be included in future research models.

Patient Satisfaction with Psoriasis Therapies: An Update and Introduction to Biologic Therapy

Background:

Psoriasis is a chronic, immune-mediated skin condition that often requires lifelong treatment. Many patients report dissatisfaction with traditional nonbiologic therapies because they are ineffective for their psoriasis, are associated with side effects, or impact negatively on quality of life.

Objectives:

The aim of this article is to review the effect on patient quality of life of traditional nonbiologic psoriasis therapies and to discuss the impact of biologic psoriasis therapies on patient satisfaction.

Methods:

A review of the literature is presented.

Results:

Traditional nonbiologic psoriasis therapies can negatively impact quality of life due to a variety of factors including inconvenience and toxicity. Biologic agents have been developed that target the immunopathogenesis of psoriasis. Based on favorable efficacy and safety results in clinical trials, some of these agents are now approved for clinical use. Evidence suggests that patients receiving biologic therapies experience significant improvements in health-related quality of life.

Conclusion:

Biologic agents offer new hope for patients with psoriasis that their chronic condition can be controlled in a manner that improves their quality of life and may lead to high levels of satisfaction with their treatment.

A patient-centred approach to biological treatment decision making for psoriasis: an expert consensus

Background

Each individual psoriasis patient has different expectations and goals for biological treatment, which may differ from those of the clinician. As such, a patient‐centred approach to treatment goals remains an unmet need in psoriasis.

Objective

The aim of this study was to review available data on patients’ and physicians’ decision criteria and expectations of biological treatment for moderate‐to‐severe psoriasis with the aim of developing a core set of questions for clinicians to ask patients routinely to understand what is important to them and thus better align physicians’ and patients’ expectations of treatment with biologics and its outcomes.

Methods

A literature search was conducted to identify key themes and data gaps. Aspects of treatment relevant when choosing a biological agent for an individual patient were identified and compared to an existing validated instrument. A series of questions aimed at helping the physician to identify the particular aspects of treatment that are recognised as important to individual psoriasis patients was developed.

Results

Key findings of the literature search were grouped under themes of adherence, decision‐making, quality of life, patient/physician goals, communication, patient‐reported outcomes, satisfaction and patient benefit index. Several aspects of treatment were identified as being relevant when choosing a biological agent for an individual patient.

The questionnaire is devised in two parts. The first part asks questions about patients’ experience of psoriasis and satisfaction with previous treatments. The second part aims to identify the treatment attributes patients consider to be important and may as such affect their preference for a particular biological treatment. The questionnaire results will allow the physician to understand the key factors that can be influenced by biological drug choice that are of importance to the patient. This information can be used be the physician in clinical decision making.

Conclusion

The questionnaire has been developed to provide a new tool to better understand and align patients’ and physicians’ preferences and goals for biological treatment of psoriasis.

Improving patient outcomes in psoriasis: strategies to ensure treatment adherence

Psoriasis is a frequent inflammatory disease with a chronic and relapsing course. Therefore, patients with psoriasis are likely to undergo different treatments for long periods of time. Traditionally, therapies used in psoriasis have been associated with poor levels of adherence due to the complexity of the regimens and the poor results obtained with the topical therapies. These poor outcomes are associated with high levels of frustration and anxiety, which decrease adherence and worsen the disease. With the recent introduction of highly efficacious biologic therapies, patients can achieve very good and prolonged responses. However, most patients with psoriasis have mild disease and may be treated with skin-directed therapies. Therefore, it is important to develop strategies to improve adherence in order to achieve better outcomes, and to improve the overall quality of life. Hence, acknowledging the causes of nonadherence is crucial for implementing these strategies. In this summary, we review the causes of nonadherence, and we provide behavioral strategies in order to improve adherence and, ultimately, the outcome of patients with psoriasis.

Clinical symptoms and self-reported disease severity among patients with psoriasis - Implications for psoriasis management

BACKGROUND

Pain, itching, burning and irritation are common symptoms of psoriasis but have not been well characterized by overall psoriasis severity.

METHODS

Using 2012 syndicated psoriasis patient survey data, 1050 subjects were classified into mild (n = 610) and moderate-to-severe (n = 440) psoriasis severity groups based on self-reporting. Demographics, comorbid medical conditions and patient-reported key symptoms (i.e. flare-up frequency, psoriasis-related pain, itching, burning, hurting, irritation) were compared between groups. Multiple regressions were employed to examine the impact of overall psoriasis severity on each key symptom, controlling for demographics and comorbidities.

RESULTS

Mild patients were older; more than 20% in both groups had joint pain and depression. Over 35 and 68% of the moderate-to-severe patients reported severe pain between or during flare-ups, respectively, and over 79% reported frequent bothersome itching. Controlling for between-group differences, moderate-to-severe patients had worse pain, were more likely to have continual flare-ups (odds ratio = 3.0) and flare-ups more than once monthly (odds ratio = 3.0), and reported more bothersome symptoms than patients with mild disease (all p < 0.05).

CONCLUSION

The presence and level of particular symptoms increase with self-reported disease severity in patients with psoriasis. Careful investigation of symptoms in tandem with clinical observation is important for effective psoriasis management.

Development and psychometric validation of the REFlective evaLuation of psoriasis Efficacy of Treatment and Severity (REFLETS) questionnaire: a common measure of plaque-type psoriasis severity and treatment efficacy for patients and clinicians

BACKGROUND

To date, there is no global consensus on the definition of the severity of psoriasis. The REFlective evaLuation of psoriasis Efficacy of Treatment and Severity (REFLETS) questionnaire has recently been developed to provide a better understanding of plaque-type psoriasis severity and treatment efficacy from both patient and clinician perspectives.

OBJECTIVE

This study aimed to develop and psychometrically validate the new REFLETS questionnaire to evaluate patient and clinician perceptions of plaque-type psoriasis severity and treatment efficacy.

METHODS

Two similar versions of the REFLETS questionnaire were developed following a rigorous methodology for clinicians and patients, referring to 'the psoriasis of your patient' or to 'your psoriasis', respectively. An observational, longitudinal, multicentre study was conducted in France with 34 dermatologists and 430 mild to severe plaque-type psoriasis patients to finalize the questionnaire and evaluate its psychometric properties.

RESULTS

Two dimensions were defined--severity and treatment efficacy--with three subdimensions within severity (impact of psoriasis, symptoms and disease course), and two individual items on joint pain. The questionnaire was well accepted by clinicians and patients. Excellent internal consistency (Cronbach's alpha = 0.66-0.98) and test-retest reliability (intraclass correlation coefficients = 0.83-0.94) were demonstrated. REFLETS scores were moderately to highly correlated to Psoriasis Area and Severity Index (r = 0.35-0.70), Skindex-29 (r = 0.46-0.82) and DLQI scores (r = 0.36-0.82). Patients with decreased psoriasis severity and those with increased treatment efficacy, according to patient global evaluations, had lower severity and higher treatment efficacy REFLETS scores, respectively.

CONCLUSION

REFlective evaLuation of psoriasis Efficacy of Treatment and Severity is a promising tool for assessing plaque-type psoriasis severity and treatment efficacy from patient and clinician perspectives. It may help to improve patient and clinician communication in treatment decision making.

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.

Recommendations for a patient-centered approach to the assessment and treatment of scalp psoriasis: a consensus statement from the Asia Scalp Psoriasis Study Group

BACKGROUND

International consensus statements on the management of scalp psoriasis are available, but no such recommendations exist for Asia.

METHODS

The Asia Scalp Psoriasis Study Group (ASPSG) met in May 2011 to review the epidemiologic pattern of scalp psoriasis in Southeast Asia and to develop Asia-specific recommendations for its management.

RESULTS

The overall prevalence of psoriasis in Asia is <0.3%, but 75-90% have scalp involvement, whether isolated or with lesions elsewhere, which can negatively impact quality of life (QoL). Treatment decisions should be based primarily on objective disease severity, but should also take account of patient QoL. Psychosocial support and more aggressive treatment should be offered to all patients with moderate to severe QoL impairment. Topical therapy is indicated first-line in all patients, with combination therapy (corticosteroid + calcipotriol), more occlusive formulations, keratolytics, and very potent corticosteroids for patients needing greater or faster efficacy. Systemic therapies, light or laser treatments should be reserved for patients with severe and recalcitrant disease.

CONCLUSIONS

The ASPSG recommends a patient-centered approach to scalp psoriasis management, consistent with the international consensus statements. Asian physicians should also consider patient QoL, prior treatment response, formulation preferences, likely adherence, cost, time available for self-management, and potential adverse events.

Care in the Context of the Complexity of Psoriasis

Previous research has demonstrated the multidimensional challenges of living with psoriasis and dermatology wards provide a unique setting in which to reach people strongly affected by this disease. The aim of this study is to determine the components of care that psoriasis patients and dermatology nurses consider to be important during hospitalization. A purposeful sample of seven psoriasis inpatients and seven dermatology nurses were interviewed in depth during a 3-month period in 2006-2007. The data are analyzed with a modified version of Giorgi’s phenomenological method. Patients consider hospitalization a relief from everyday life with psoriasis and describe its treatment as the focus of nursing care. Despite their knowledge of the psychosocial aspects of psoriasis, nurses consider the physical manifestations of the disease most important. The patients’ descriptions of the challenges in their everyday lives illustrate an area of concern among psoriasis inpatients that is not actively addressed by nursing care.

Assessing the Impact of Psoriasis and the Relevance of Qualitative Research

Living with psoriasis is a lifetime experience. The lack of a cure combines with a peculiar public response of disinterest if not prejudice and stigmatization. Various factors account for changes in quality of life measures that seem independent from disease severity and effectiveness of treatment. Merging a qualitative and individual case analysis with assessment of quality of life would represent a direction for future studies.

Patient satisfaction with psoriasis therapies: an update and introduction to biologic therapy

BACKGROUND

Psoriasis is a chronic, immune-mediated skin condition that often requires lifelong treatment. Many patients report dissatisfaction with traditional nonbiologic therapies because they are ineffective for their psoriasis, are associated with side effects, or impact negatively on quality of life.

OBJECTIVES

The aim of this article is to review the effect on patient quality of life of traditional nonbiologic psoriasis therapies and to discuss the impact of biologic psoriasis therapies on patient satisfaction.

METHODS

A review of the literature is presented.

RESULTS

Traditional nonbiologic psoriasis therapies can negatively impact quality of life due to a variety of factors including inconvenience and toxicity. Biologic agents have been developed that target the immunopathogenesis of psoriasis. Based on favorable efficacy and safety results in clinical trials, some of these agents are now approved for clinical use. Evidence suggests that patients receiving biologic therapies experience significant improvements in health-related quality of life.

CONCLUSION

Biologic agents offer new hope for patients with psoriasis that their chronic condition can be controlled in a manner that improves their quality of life and may lead to high levels of satisfaction with their treatment.

Age, gender, quality of life and psychological distress in patients hospitalized with psoriasis

BACKGROUND

Psoriasis has a great impact on the quality of life of patients, and the ageing population is an important public health issue.

OBJECTIVES

To investigate whether older patients with psoriasis have a different impairment in quality of life compared with younger patients, considering level of severity, duration of disease, gender and psychological distress.

METHODS

The study was performed between February 2000 and February 2002 at the inpatient wards of the Dermatological Institute IDI-IRCCS, Rome, Italy, in the framework of a large project on clinical, epidemiological, emotional and quality of life aspects of psoriasis (IMPROVE study). This is a hospital-based cross-sectional study, with measures of quality of life (Skindex-29, Dermatology Life Quality Index and Psoriasis Disability Index) and of psychological distress, generic (12-item General Health Questionnaire) and psoriasis-related (Psoriasis Life Stress Inventory), all self-assessed by patients. We compared the mean scores of each quality of life instrument in patients aged < 65 years and >/= 65 years, in subsets of patients based on clinical and sociodemographic characteristics.

RESULTS

We analysed 936 patients hospitalized at IDI-IRCCS with a diagnosis of psoriasis. Quality of life was significantly more impaired in the older group for all the Skindex-29 scales, and psychological distress was higher in older patients. In particular, older women suffering from anxiety or depression had the greatest impairment in quality of life. The results were somewhat different using the other quality of life instruments.

CONCLUSIONS

These results should alert dermatologists that similar levels of clinical severity in psoriasis may be associated with different levels of quality of life and psychological distress of patients. Particular attention should be devoted to older patients, and especially to older women.

Traditional systemic treatments have not fully met the needs of psoriasis patients: Results from a national survey

BACKGROUND

Many psoriasis patients are dissatisfied with current therapies. However, patient-centered levels of satisfaction with individual treatments have not been well described.

OBJECTIVE

To assess patients' satisfaction with 4 systemic treatment options available before 2002.

METHODS

We used data from a recent national survey. Psoriasis patients were randomly recruited from the general US population, members of the Psoriasis Foundation, and persons who contacted the Psoriasis Foundation but did not join. The interview included questions about use and satisfaction with specific Psoriasis therapy.

RESULTS

Of 1197 psoriasis patients interviewed, 311 (26%) indicated current or past use of methotrexate, psoralen plus ultaviolet A (PUVA), cyclosporin, and/or acitretin (users). Compared with those who had never used any of these systemic therapies, users reported more extensive disease (adjusted odds ratio [OR] = 2.90, 95% confidence interval [CI] = 1.87-4.49) and higher Psoriasis Disability Index scores (category V: adjusted OR = 2.31, 95% CI = 1.22-4.36). After adjusting for these variables, more than one third of patients were dissatisfied with each therapy, except for PUVA (14%). Patients were most satisfied with methotrexate and PUVA. However, less than 40% of the users indicated they were very satisfied with any of the 4 therapies assessed. Only 10% of persons who ever used cyclosporin were currently using it. In a paired analysis, cyclosporin users were significantly less satisfied with cyclosporin than with other therapies ( P = .01).

CONCLUSION

For most patients, none of the 4 systemic therapies widely utilized in 2002 for psoriasis were highly satisfactory. If we are to learn whether new treatments satisfy patients' needs, long term, prospective, comparative studies of heterogeneous patient populations that include patients' assessments are needed.