Disease severity measures in a population of psoriasis patients: the symptoms of psoriasis correlate with self-administered psoriasis area severity index scores

Factors Associated with Treatment Satisfaction in Korean Patients with Psoriasis

Purpose

Treatment satisfaction among patients with psoriasis can vary significantly based on available treatment options and individual patient characteristics.

Patients and Methods

This cross-sectional study utilized psoriasis-specific questionnaires to assess treatment satisfaction and identify the factors associated with treatment satisfaction in Korean patients. The study included 350 eligible patients aged 19 or older from a nationwide psoriasis group. Participants completed a self-reported web-based questionnaire assessing socioeconomic and clinical status, quality of life, and treatment satisfaction. Linear regression models were employed to analyze the factors associated with treatment satisfaction.

Results

The results showed that patients with mild to moderate psoriasis, as determined by the body surface area involvement, had higher satisfaction scores for treatment effectiveness. Moreover, patients receiving biologic therapies reported significantly higher total satisfaction scores and scores across all domains than those not utilizing biologics. However, patients reporting poorer quality of life or experiencing anxiety exhibited lower satisfaction scores.

Conclusion

Findings suggest that while biologic treatments may confer greater satisfaction to patients with psoriasis, diminished quality of life and anxiety can negatively impact satisfaction levels. The study underscores the importance of understanding the factors associated with patient satisfaction to optimize treatment outcomes in psoriasis management.

Effects of a Brief Mindfulness-based Intervention in Patients with Psoriasis: A Randomized Controlled Trial

Mindfulness is a special type of attention, namely focusing on the current moment in a non-judgmental manner. Extensive mindfulness-based interventions have been shown to have positive effects in patients with psoriasis. However, it is unclear whether brief (2-week) interventions are also beneficial. Therefore, the aim of this study was to investigate the effects of a 2-week mindfulness-based intervention in patients with psoriasis. Patients were randomly assigned to an experimental (treatment-as-usual + mindfulness-based intervention) or control group (treatment-as-usual) during their clinic stay. All variables were measured by self-report using validated questionnaires: primary outcomes were mindfulness and self-compassion, secondary outcomes were itch catastrophizing, social anxiety, stress and skin status. Variables were assessed prior to, immediately and 3 months after the intervention. Effects were tested by repeated-measures analysis of variance (ANOVA). Analyses of pre-post-measurements (n = 39) revealed a significant interaction effect on self-reported mindfulness [F(1,35) = 7.46, p = 0.010, η2p = 0.18] and a tendency to a significant effect on self-reported self-compassion [F(1,36) = 3.03, p = 0.090, η2p = 0.08]. There were no other significant effects, but most descriptive data were in favour of the experimental group. However, the control group showed a greater improvement in skin status. Further studies are needed to replicate these findings and investigate which subgroups especially profit from such an intervention.

A description of treatment patterns of psoriasis by medical providers and disease severity in US women

Background

Studies on treatment patterns of psoriasis are valuable to evaluate how efficiently individuals with psoriasis are treated and may facilitate improved outcomes for these patients.

Objective

To describe treatment patterns of psoriasis among US women.

Methods

In the Nurses' Health Study II (NHS II), a prospective study of female nurses, 2107 women reported to have a diagnosis of psoriasis made by a clinician. We sent them the Psoriasis Screening Tool-2, a validated diagnostic tool for psoriasis, which queries age at diagnosis, treatments, type of psoriasis lesions, body surface area involved, and the provider who made the diagnosis.

Results

A total of 1382 women completed and returned the survey, with 1243 of them validated for having psoriasis. 30% of the patients were diagnosed by non-dermatologists. 79% of the patients reported mild, 17% moderate and 4% severe disease. Psoriasis phenotypes were as follows: plaque 41%, scalp 49%, inverse 27%, nail 22% and palmoplantar 15%. Treatment patterns for mild psoriasis were as follows: only topical treatment 58%, systemic therapy and/or phototherapy 16% and no treatment 26%. Treatment patterns for moderate-to-severe disease were as follows: only topical treatment 42%, systemic therapy and/or phototherapy 47% and no treatment 11%.

Conclusion

The majority of women in NHS II with psoriasis have mild disease. A large proportion of psoriasis patients were diagnosed by non-dermatologists. More than half of people with moderate-to-severe disease received no treatment or only topical medications. A considerable percentage of people with psoriasis reported phenotypes other than chronic plaque psoriasis.

Prevalence of psoriatic arthritis in patients with psoriasis: A systematic review and meta-analysis of observational and clinical studies

BACKGROUND

Wide-ranging prevalence estimates of psoriatic arthritis (PsA) in patients with psoriasis have been reported.

OBJECTIVES

To assess the prevalence and incidence of PsA in patients with psoriasis.

METHODS

Two authors independently searched 3 databases for studies reporting on the prevalence or incidence of PsA in patients with psoriasis. A proportion meta-analysis was performed to calculate the pooled proportion estimates of PsA in patients with psoriasis.

RESULTS

A total of 266 studies examining 976,408 patients with psoriasis were included. Overall, the pooled proportion (95% confidence interval [CI]) of PsA among patients with psoriasis was 19.7% (95% CI, 18.5%-20.9%). In children and adolescents (<18 years of age), the pooled prevalence was 3.3% (95% CI, 2.1%-4.9%). The PsA prevalence was 22.7% (95% CI, 20.6%-25.0%) in European patients with psoriasis, 21.5% (95% CI, 15.4%-28.2%) in South American patients with psoriasis, 19.5% (95% CI, 17.1%-22.1%) in North American patients with psoriasis, 15.5% (95% CI, 0.009%-51.5%) in African patients with psoriasis, and 14.0% (95% CI, 95% CI, 11.7%-16.3%) in Asian patients with psoriasis. The prevalence of PsA was 23.8% (95% CI, 20.1%-27.6%) in studies in which the Classification Criteria for Psoriatic Arthritis were applied. The incidence of PsA among patients with psoriasis ranged from 0.27 to 2.7 per 100 person-years.

LIMITATIONS

Between-study heterogeneity may have affected the estimates.

CONCLUSIONS

We found that 1 in 4 patients with psoriasis have PsA. With the growing recognition of the Classification Criteria for Psoriatic Arthritis, more homogenous and comparable prevalence estimates are expected to be reported.

Methylenetetrahydrofolate reductase (MTHFR) C677T polymorphism in psoriasis in southern Turkey

Background

Psoriasis is a multigenic and multifactorial dermatological disease linked to cardiovascular diseases. Increased levels of homocysteine in patients with psoriasis have been demonstrated in many studies. The most frequently investigated genetic defect that plays a role in homocysteine metabolism is single point substitution (C to T) located on the 677th nucleotide of the methylenetetrahydrofolate reductase gene (MTHFR).

Objective

In this study, we aimed to investigate methylenetetrahydrofolate C677T polymorphism in psoriasis patients in Turkey.

Methods

The study included 96 patients with psoriasis and 77 controls from southern Turkey. Methylenetetrahydrofolate C677T polymorphism was analysed using the Polymerase Chain Reaction-Restriction Fragment Length Polymorphism methods.

Results

In the psoriasis group, 34 CC (35.4%), 46 CT (47.9%) and 16 TT (16.7%) genotypes were found, respectively; while in the control group, the figures were 39 (50.6%), 35 (45.5%), 3 (3.9%). Homozygote and heterozygote T alleles of methylenetetrahydrofolate C677T polymorphism were significantly higher in the psoriasis than in the control group (p=0.013).

Conclusion

We firstly found a correlation between methylenetetrahydrofolate C677T polymorphism and psoriasis among the southern Turkish population.

Ethnopharmacological survey of medicinal plants used by patients with psoriasis in the West Bank of Palestine

Background

Psoriasis is a frequent skin inflammatory disorder that inflicts millions of patients around the globe. To meet their healthcare needs, patients with psoriasis often seek treatment outside the allopathic paradigm. Use of medicinal plants has emerged as one of the most common and preferred modalities of complementary and alternative medicine (CAM). The aim of this study was to investigate the use of medicinal plants by patients with psoriasis in the West Bank of Palestine.

Methods

The current study was a questionnaire based cross-sectional descriptive study on the use of medicinal plants by psoriasis patients in the West Bank of Palestine. A sample of 149 patients with psoriasis who were visiting outpatient clinics responded to the questionnaire in face to face interviews.

Results

Medicinal plants were used by 81 (54.4%) patients with psoriasis. Patients used 33 medicinal plants belonging to 26 families. Plants belonging to Lamiaceae and Leguminosae were the most commonly used by the study patients. Aloe vera, Trigonella arabica, Catharanthus roseus and Anthemis cotula were the most frequently used medicinal plants to treat psoriasis. Leaves and fruits were the most commonly used parts by the study patients. Paste was the most commonly used form of preparation. The use of medicinal plants was significantly associated with age and monthly household income of the patients. Enhancement of immunity, improving conventional therapy and reduction of side effects were the most commonly self-reported reasons for using medicinal plants.

Conclusions

Patients with psoriasis in Palestine seem to use medicinal plants as a CAM modality to manage their psoriasis. Many medicinal plants were commonly used by patients with psoriasis. More randomized clinical trials are needed to demonstrate safety and efficacy for the majority of these medicinal plants reported to be used by patients with psoriasis in Palestine.

Electronic supplementary material

The online version of this article (doi:10.1186/s12906-016-1503-4) contains supplementary material, which is available to authorized users.

The Physical, Psychological and Social Impact of Psoriasis

Psoriasis is a chronic, disabling skin disease affecting up to 2 percent of the population. Little is known about how physical, psychological and social features of the illness interact to create a negative impact. In this article, a biopsychosocial model of the impact of psoriasis is described, and results from a survey of 317 psoriasis patients are presented. The types of functional disability, psychological distress and disease-related stressors are described for highly strained patients (i.e. those with disease-related suicidal ideation) and compared with less strained patients (i.e. those without suicidal ideation). As predicted by the model, significantly more disability, psychological distress and disease-related stressors are found among highly strained patients. Logistical regression analysis revealed that strain is more strongly associated with disability, distress and disease-related stress level than with disease severity. Implications for research and clinical interventions are discussed.

Relationship between Histological and Clinical Course of Psoriasis: A Pilot Investigation by Reflectance Confocal Microscopy during Goeckerman Treatment

Alterations of the skin microvasculature are known to play an important role in the development and maintenance of psoriatic skin lesions. In this study, we investigated lesional skin in 11 psoriatic patients during a modified Goeckerman treatment using reflectance confocal microscopy (RCM) to study the relationship between clinical clearance and histological normalization of psoriatic skin and the significance of histological abnormalities on the course of disease. The treatment regimen resulted in a significant reduction of the Psoriasis Area and Severity Index (PASI) as well as capillary and papillary diameters (p < 0.0001). The capillary and papillary diameters were still enlarged when compared to those in normal skin (p < 0.001). Capillary and papillary diameters correlated with each other prior to and after treatment (correlation coefficient = 0.63 and 0.64, p = 0.01 and 0.002, respectively) but not with the PASI. Capillary and papillary diameters after treatment and percentage reduction of the PASI during treatment seemed to be better predictors for the clinical course of relapse than the PASI after treatment. These findings make the subclinical changes of psoriatic skin vessels and dermal papillae a legitimate target for treatment. Further investigations of a large group of patients are needed to evaluate the potential of RCM findings as successor of the PASI in the monitoring of psoriasis.

Assessment of pruritus in patients with psoriasis and atopic dermatitis: subjective and objective tools

Pruritus is a major symptom of skin disease. The quest to identify a valid and reliable method to assess this important symptom has led to the development of a myriad of measurement tools. Some clinical trials using subjective measurements of itch intensity have reported itch intensity levels in psoriasis that are close to severity levels found in atopic dermatitis. Although it is possible that we have previously underestimated the severity of pruritus in psoriasis, these unexpected findings prompted us to review and evaluate these subjective methodologies. We provide an overview of the current tools available to measure itch severity, including subjective rating scales and questionnaires and objective measures of scratch activity through videotape observation and wrist actigraphy. We discuss the advantages and limitations of these methods and encourage consideration of a novel objective method of evaluation.

Screening for Psoriatic Arthritis in Korean Psoriasis Patients Using the Psoriatic Arthritis Screening Evaluation Questionnaire

Background

Psoriatic arthritis (PsA) is chronic seronegative inflammatory arthritis that causes irreversible joint damage. Early recognition of PsA in patients with psoriasis is important for preventing physical disability and deformity. However, diagnosing PsA in a busy dermatology outpatient clinic can be difficult.

Objective

This study aimed to validate the Psoriatic Arthritis Screening and Evaluation (PASE) questionnaire for the detection of PsA in Korean patients with psoriasis.

Methods

The PASE questionnaire was prospectively given to 148 patients diagnosed with psoriasis but without a previous diagnosis of PsA. All patients underwent radiologic and laboratory examinations, and a subsequent clinical evaluation by a rheumatologist.

Results

Eighteen psoriasis patients (12.2%) were diagnosed with PsA according to the Classification Criteria for Psoriatic Arthritis. The PASE questionnaire scores of differed significantly between PsA and non-PsA patients. Receiver operator characteristic analysis showed an area under the curve of 0.82 (95% confidence interval: 0.72, 0.92) for PASE score. A PASE score cut-off of 37 points had a sensitivity of 77.8% and specificity of 82.3% for the diagnosis of PsA.

Conclusion

The PASE questionnaire is a simple and convenient screening tool for detecting PsA in Korean dermatology clinics. A PASE questionnaire score of 37 points appears to be an appropriate cut-off for screening Korean psoriasis patients.

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.

Physical and mental impact of psoriasis severity as measured by the compact Short Form-12 Health Survey (SF-12) quality of life tool

The Short Form-12 Health Survey (SF-12) is used to assess the patient's quality of life (QoL) using the physical component score (PCS) and the mental component score (MCS). The purpose of this study was to determine whether the SF-12 PCS and MCS are associated with psoriasis severity and to compare QoL between Murdough Family Center for Psoriasis (MFCP) patients and patients with other major chronic diseases included in the National Survey of Functional Health Status data. We used data from 429 adult patients enrolled in MFCP. Psoriasis Area Severity Index (PASI) was used to assess psoriasis severity at the time of completion of the SF-12 questionnaire. Other variables included age, sex, body mass index, psoriatic arthritis, psychiatric disorders, and comorbidities. Linear regression models were used to estimate effect sizes ± 95% confidence intervals. For every 10-point increase in PASI, there was a 1.1 ± 1.3 unit decrease in MCS (P=0.100) and a 2.4 ± 1.3 unit decrease in PCS (P<0.001). Psoriasis severity was associated with PCS and MCS after adjusting for variables, although the strength of the relationship was attenuated in some models. Psoriasis severity is associated with decreased QoL. SF-12 may be a useful tool for assessing QoL among psoriasis patients.

Quality of life and sexual health in patients with genital psoriasis

BACKGROUND

Knowledge about quality of life and sexual health in patients with genital psoriasis is limited.

OBJECTIVES

We studied quality of life and sexual function in a large group of patients with genital psoriasis by means of validated questionnaires. In addition, we evaluated whether sufficient attention is given by healthcare professionals to sexual problems in patients with psoriasis, as perceived by the patients.

METHODS

A self-administered questionnaire was sent to 1579 members of the Dutch Psoriasis Association. Sociodemographic patient characteristics, medical data and scores of several validated questionnaires regarding quality of life (Dermatology Life Quality Index) and sexual health (Sexual Quality of Life Questionnaire for use in Men, International Index of Erectile Function, Female Sexual Distress Scale and Female Sexual Function Index) were collected and analysed.

RESULTS

This study (n = 487) shows that psoriasis has a detrimental effect on quality of life and sexual health. Patients with genital lesions reported even significantly worse quality of life than patients without genital lesions (mean ± SD quality of life scores 8·5 ± 6·5 vs. 5·5 ± 4·6, respectively, P < 0·0001). Sexual distress and dysfunction are particularly prominent in women (reported by 37·7% and 48·7% of the female patients, respectively). Sexual distress is especially high when genital skin is affected (mean ± SD sexual distress score in patients with genital lesions 16·1 ± 12·1 vs. 10·1 ± 9·7 in patients without genital lesions, P = 0·001). The attention given to possible sexual problems in the psoriasis population by healthcare professionals is perceived as insufficient by patients.

CONCLUSIONS

In addition to quality of life, sexual health is diminished in a considerable number of patients with psoriasis and particularly women with genital lesions have on average high levels of sexual distress. We underscore the need for physicians to pay attention to the impact of psoriasis on psychosocial and sexual health when treating patients for this skin disease.

Insight into psoriasis management: commercial perspectives for the U.S. psoriasis market

Psoriasis is a chronic skin condition that has a significant impact on quality of life, self-esteem and comorbidities. Management of this condition is complicated and heavily influenced by psychosocial and economic realities. Addressing psychosocial and treatment education issues can be facilitated by use of the National Psoriasis Foundation. Localized disease is generally treated with topical treatment for which good generic medications are available. Somewhat higher priced branded vehicles are helpful for enhancing patients' treatment adherence, and may help avoid the need for far more toxic and expensive systemic treatment. Patients with extensive disease are best managed with phototherapy as a first-line option, and there is room for improvement in how insurers promote the use of this approach. Biologic treatments continue to offer new, safer options for patients with severe disease, albeit at higher cost. This review addresses practical issues in psoriasis management that would be of interest to organizations that are involved in the delivery of care for patients with psoriasis, such as managed care pharmacists and pharmaceutical companies that develop products for psoriasis.

A multi-dimensional health assessment questionnaire (MDHAQ) and routine assessment of patient index data (RAPID3) scores are informative in patients with all rheumatic diseases

Although indices have been developed for many rheumatic diseases in usual care, they are rarely used in usual care. In most visits to rheumatologists, the only quantitative data collected are laboratory tests. Patient history data often are more important in management of patients with rheumatic diseases than other diseases. A two-page multidimensional health assessment questionnaire (MDHAQ) can be completed by the patient in 5 to 10 minutes and reviewed by the physician in 10 seconds, with RAPID3 scored in 5 to 10 seconds. The MDHAQ is useful in rheumatic diseases, to improve management documentation and outcomes. MDHAQ data for physical function, pain, global status, and RAPID3 scores appear preferable to no quantitative data.

Reliability, validity and responsiveness to change of the Patient Report of Extent of Psoriasis Involvement (PREPI) for measuring body surface area affected by psoriasis

BACKGROUND

The development of a simple, reliable, valid and responsive method for measuring the extent of skin involvement in psoriasis is important for use in epidemiological studies.

OBJECTIVES

We sought to investigate the psychometric characteristics of the Patient Report of Extent of Psoriasis Involvement (PREPI), a single-question method for measuring body surface area affected by psoriasis.

METHODS

This was a cross-sectional study of 140 patients with psoriasis, with an exploratory prospective longitudinal cohort component. Reliability was measured via a test-retest approach and criterion validity was investigated by comparing the PREPI with an assessment of body surface area of involvement by a dermatologist. We additionally compared Skindex-29 scores with the PREPI. To demonstrate responsiveness and establish a minimally important difference in the PREPI, we created receiver operating characteristic curves for the PREPI instrument.

RESULTS

The test-retest reliability of the PREPI was nearly perfect [intraclass correlation coefficient (ICC) = 0.99, 95% confidence interval (CI) 0.97-0.99], and there was substantial agreement between patient and physician assessments (ICC = 0.82, 95% CI 0.75-0.87). The PREPI showed significant correlations with all Skindex-29 domains. We found the PREPI to be responsive to change and identified changes in the PREPI score that have good discrimination between patients with and without a minimally important clinical difference.

CONCLUSIONS

Our study suggests that the PREPI is a reliable, valid and responsive measure of body surface area affected by psoriasis that may be useful for future epidemiological research.

Giving patients ‘perceived control’ over psoriasis: advice for optimizing the physician–patient relationship

Patients with psoriasis suffer from the effects of a chronic illness. One of the most bothersome aspects of the disease is a sense of loss of 'control.' 'Perceived control' is an important and well-studied psychological concept. The literature on perceived control offers guidance to help improve the physician-patient relationship and outcomes in chronic diseases such as psoriasis. Practical suggestions include the use of materials and other resources offered by patient advocacy groups (such as those from the National Psoriasis Foundation) and the development of a physician-patient relationship that gives the patient a sense of control of their disease.

Class I topical corticosteroid use by psoriasis patients in an academic practice

BACKGROUND

Psoriasis is a chronic skin disorder that can have a profound impact on the quality of life of patients. The treatment of psoriasis is complicated by the availability of numerous topical agents, systemic agents, and phototherapy. Of the topical preparations available, the ultra-high potency, or Class I steroids, have an important role in treating psoriasis. Their use is most appropriate for the treatment of plaques in regions excluding the face, axilla, groin and genitals.

OBJECTIVE

The purpose of this study was to examine the prescribing patterns of Class I topical corticosteroids within a large academic dermatology practice for patients with all types of psoriasis.

METHODS

A retrospective chart review of 650 patients with psoriasis from an academic dermatology practice was performed. Class I steroid use was defined as those patients who were observed to be currently using clobetasol propionate, halobetasol propionate, diflorasone, or augmented betamethasone dipropionate.

RESULTS

A total of 79% of patients were prescribed topical steroids of any class while 46% of patients were prescribed a Class I steroid. In all, 58% of patients who received topical steroid therapy received a Class I agent; 11% of patients prescribed Class I steroids also received systemic therapy for their psoriasis. Conversely, 35% of patients who received systemic therapy were also receiving Class I topical therapy.

DISCUSSION

In our department, Class I topical steroids are commonly used in the treatment of psoriasis. The superpotent topicals are often used as an adjunct to systemic therapy and will likely remain a mainstay of psoriasis therapy.

Adalimumab treatment is associated with improvement in health‐related quality of life in psoriasis: Patient‐reported outcomes from a Phase II randomized controlled trial

BACKGROUND

Psoriasis substantially impairs the health-related quality of life (HRQOL) of patients, and a comprehensive evaluation of treatment includes HRQOL measures.

OBJECTIVE

To assess the impact of adalimumab on patient-reported outcomes (PROs) of patients with moderate to severe psoriasis.

METHODS

In a Phase II, randomized, controlled trial, the efficacy and safety of two dosages of adalimumab (40 mg weekly or every other week) versus placebo were assessed for 12 weeks in the treatment of moderate to severe plaque psoriasis. Patients completed the Dermatology Life Quality Index (DLQI), Short-Form 36 (SF-36) Health Survey, and EuroQOL-5D (EQ-5D) at baseline and 12 weeks. The primary endpoint was the percentage of patients achieving a > or =75% reduction in the Psoriasis Area and Severity Index score (PASI 75). Investigators assessed PASI and Physician's Global Assessment (PGA) scores.

RESULTS

Adalimumab patients (either dosage) displayed significantly greater improvements versus placebo patients in DLQI, EQ-5D, and SF-36 Mental Component Summary scores, as well as in Bodily Pain, Vitality, Social Functioning, Role-Emotional, and Mental Health domains. The adalimumab 40-mg weekly group also reported significantly greater improvements in SF-36 Physical Component Summary scores versus the placebo group.

CONCLUSION

Both adalimumab dosages were efficacious in improving dermatology-specific and general PROs in patients with moderate to severe psoriasis.

Quantitative measures of rheumatic diseases for clinical research versus standard clinical care: differences, advantages and limitations

No single measure can serve as a 'gold standard' for the diagnosis, prognosis, and monitoring of patients with rheumatic diseases. Therefore, pooled indices of several measures have been developed for patient assessment. Quantitative measures and indices in rheumatology have been used primarily in clinical trials and other clinical research, but not in standard clinical care. Indeed, most standard rheumatology care is conducted without quantitative data other than laboratory tests, which often are uninformative. Some measures used in research have been adapted for standard care. The classical 66/68-joint count with graded scoring for swelling, tenderness, pain on motion, limited motion, and deformity has been shortened for clinical care to a 28-joint count, scored only as 'Yes' or 'No' for swelling or tenderness. Patient questionnaires designed for clinical research can be lengthy, with complex scoring, so that information is not available to help guide clinical decisions. By contrast, patient questionnaires designed for standard care, such as a simple one-page, multi-dimensional health assessment questionnaire (MDHAQ), are short, save time, are easily scored, and are useful in all rheumatic diseases to monitor patient status at each visit and document changes over long periods. More attention to measures for use in standard care could improve care and outcomes for patients with rheumatic diseases.

The reduced Impact of Psoriasis Questionnaire has good psychometric properties in Italian patients

BACKGROUND

A recent refinement study suggested that a Rasch reduced version of the Impact of Psoriasis Questionnaire (IPSO) of 11 items most adequately assessed the psychosocial impact of US psoriasis patients.

OBJECTIVE

To test whether the IPSO would also behave well in a different population that varies culturally, demographically, and in disease severity.

METHODS

The psychometric properties of the IPSO, using classical test and item response theory (Rasch analysis), were assessed in 805 Italian psoriasis patients.

RESULTS

Patients with more severe psoriasis reported significantly higher impact on their HRQOL (p < 0.001) and the IPSO correlated well with the Skindex-29 (r = 0.74) confirming its validity. The response distribution was adequate for all items, except item 9. The Cronbach's alphas were excellent and the high item-rest correlations confirmed its homogeneity. Principal component analysis demonstrated one dominant factor with an eigenvalue of 4.47 (items loading >0.40). Overall, the 11 IPSO items fitted the Rasch model (p = 0.07) and all items demonstrated a logical threshold order. Of the 11 items, 2 items showed significant individual misfit and only 1 item demonstrated significant differential item functioning for age but none for gender or global severity score.

CONCLUSION

The 11-item IPSO is a valuable psoriasis-specific HRQOL instrument in different populations.

No long-term changes in psoriasis severity and quality of life following climate therapy

This paper describes disease severity and quality of life of 286 patients who underwent climate therapy. The lowest disease severity and better life quality occurred 2 weeks after therapy. However, by 4 and 8 months after therapy, all measures had returned to approximately the same level as before treatment.

Adherence to treatment in patients with psoriasis

Non-adherence to medication is a chronic problem that impacts on healthcare professionals and patients alike. In psoriasis, a condition that presents patients with frequent and disabling physical, psychological and social effects, studies consistently suggest that up to 40% of patients do not use their medication as directed. Thus it is probable that poor adherence contaminates the clinical picture of response effectiveness in everyday practice. This educational paper reviews research that investigates adherence to medication in patients with psoriasis. It provides an overview of contributing factors and mediating variables. It is proposed that three specific facets appear to optimize patient adherence: an effective doctor-patient relationship; optimism with the treatment prescribed; and a limited 'nuisance' value of treatment in terms of side-effects and hassle of use. Various strategies to address adherence are suggested and it is argued that in order to enhance our understanding of adherence in patients with psoriasis, there needs to be an increasing focus on patients' beliefs about their condition and its management.

The comorbid state of psoriasis patients in a university dermatology practice

BACKGROUND

Psoriasis treatment is frequently complicated by the various types and severities of disease as well as the large number of therapies available. Another critical consideration in treatment planning is the presence of comorbid diseases.

PURPOSE

The purpose of this study was to evaluate the relative prevalence of major comorbid disease states in patients with psoriasis and to identify significant predictors of these concurrent diseases in such patients.

METHODS

A retrospective chart review of 753 patients from an academic dermatology practice was performed. The patients were identified by ICD-9 code for psoriasis in billing records of patients seen between 1997 and 2000. Data on comorbidities were compiled from review of electronic chart notes from all physician visits in the university practice.

RESULTS

Comorbid diagnoses were listed in 551 out of 753 (73%) charts. As would be expected, hypertension, dyslipidaemia, diabetes and heart disease were the most common comorbidities; renal failure and hepatitis were least likely. Hepatitis was associated with use of systemic therapies (odds ratio = 2.19) and non-white race. When compared with national prevalence estimates, psoriasis patients had increased heart disease, hypertension, diabetes and emphysema; however, these findings must be interpreted with some caution.

CONCLUSIONS

Comorbid diseases are common in psoriasis patients and should be taken into account during treatment planning and surveillance; they may pose unique challenges in caring for patients with psoriasis, particularly those requiring systemic therapy.

A randomized, multicenter, double-blind, placebo-controlled phase 2 trial of ISA247 in patients with chronic plaque psoriasis

BACKGROUND

Use of current oral calcineurin inhibitors for the treatment of psoriasis is limited by toxicity.

OBJECTIVE

Evaluate the safety and efficacy of ISA247, a new oral calcineurin inhibitor, in plaque psoriasis patients.

METHODS

This 12-week, randomized, double-blind, placebo-controlled, parallel-group study included 201 plaque psoriasis patients with > or = 10% body surface area involvement. Patients were randomized to placebo, ISA247 0.5 mg/kg/d, and ISA247 1.5 mg/kg/d groups. End points included a 2-point reduction in the Static Global Assessment score and a 75% reduction in the Psoriasis Area and Severity Index.

RESULTS

A 2-point SGA reduction was achieved in 0% (placebo), 15.6% (0.5 mg/kg/d), and 45.1% (1.5 mg/kg/d) (P < .0001). A 75% reduction in the Psoriasis Area and Severity Index was achieved in 0% (placebo), 18.2% (0.5 mg/kg/d), and 66.7% (1.5 mg/kg/day) (P < .0001). While serum creatinine increased in patients treated with ISA247 1.5 mg/kg/d, it remained within the normal range.

LIMITATIONS

Longer-term studies are needed to evaluate the effect of ISA247 on renal function.

CONCLUSION

ISA247 appears safe and effective for treating moderate to severe psoriasis.

Collecting a set of psoriasis family material through a patient organisation; clinical characterisation and presence of additional disorders

BACKGROUND

The aim of the present study was to describe the clinical characteristics of a population of psoriatics sampled from a patient organisation and not from hospitals or out-patient clinics. Furthermore, we wanted to compare siblings with and without psoriasis regarding the occurrence of other diseases.

METHODS

At the end of 1991, we initiated a project which aimed to study genetic factors leading to psoriasis. Firstly, we sent questionnaires to all the members of the Swedish Psoriasis Association. We then examined 1,217 individuals (570 with psoriasis) from 310 families, in their homes in the southern part of Sweden. All the available family members were examined clinically and asked about the course of the skin disease and the occurrence of other diseases. The eight hundred members of the proband generation were divided into two groups, with or without psoriasis, and their clinical features were compared.

RESULTS

Most individuals in this study population had a mild form of psoriasis. The siblings with psoriasis had joint complaints significantly more frequently than their siblings without the skin disease and those with joint complaints had more widespread skin disease. Among the other studied concomitant diseases (iritis, heart or hypertension disease, endocrine disease, inflammatory bowel disease and neurological disease), we were not able to find any difference. Seventy-seven of 570 persons were found to be in remission (13.5%). Females had a mean onset 2.5 years earlier than males. We were not able to find any correlation between the extent of the skin disease and age at onset. Twice as many persons with joint complaints were found among those with psoriasis than among those without, 28% versus 13%. Almost half (48%) the psoriatics who also had joint complaints had psoriasis lesions on their nails. Endocrine disorders were found in 9% of those without any allele for Cw6, but only in 1% of those who had Cw6. In fact, none of 183 Cw6 carriers had diabetes, as compared to the population prevalence of 3-5% in Sweden.

CONCLUSION

With the exception of joint complaints, persons with psoriasis, collected from a patient organisation, did not have an increased frequency of (studied) co-existing diseases.

Psychologic Factors in Psoriasis: Consequences, Mechanisms, and Interventions

The article examines the English-language research literature concerning psychologic aspects of psoriasis published since 1995. The literature is concerned with (1) the consequences of psoriasis in terms of quality of life, disability, depression, anxiety, and stigmatization and factors that may predict such outcomes; (2) potential mechanisms of the interaction between psychologic factors, stress, and the pathophysiology of psoriasis; and (3) examination of the clinical utility of psychologic interventions on extent of psoriasis and psychologic distress. The implications of the findings are discussed with reference to future directions for research and practice.

Diagnosis and treatment of psoriatic arthritis

Psoriatic arthritis is a chronic, heterogeneous disease whose pathogenesis is unknown, although genetic, environmental, and immunologic factors play major roles. Psoriatic arthritis can follow an aggressive clinical course, and differentiating it from other arthropathies is sometimes difficult. Diagnosis of psoriatic arthritis is based on history, physical examination, the usual absence of rheumatoid factor, and characteristic radiographic features. At least 40% of patients with psoriatic arthritis develop radiographically detectable joint destruction; therefore, proper diagnosis and early treatment can have a significant impact on disease course and outcome. Understanding the pathogenesis of psoriatic disease has led to the use of several biologic agents that work by modulating T-cell signaling or by inhibiting key cytokines involved in inflammation, such as tumor necrosis factor (TNF). TNF inhibitors have demonstrated excellent efficacy in resolving skin and joint disease in patients with psoriatic arthritis and have been shown to be safe agents in various inflammatory disorders. This article reviews the diagnostic and treatment challenges of psoriatic arthritis as they relate to pathogenesis and burden of disease.

LEARNING OBJECTIVE

At the conclusion of this learning activity, participants should have acquired a more comprehensive knowledge of our current understanding of the classification, clinical presentation, etiology, pathophysiology, differential diagnosis, and treatment of psoriatic arthritis.

Decision points for the initiation of systemic treatment for psoriasis

Psoriasis has a tremendous effect on health-related quality of life. Phototherapy and systemic treatments are used for patients with more debilitating (physically and emotionally) forms of the disease. These treatments can be extremely effective but can also have potentially significant adverse effects. The decision to undertake systemic treatment of psoriasis is a complex one that requires both experience and judgment. With the recent advent of new biologic systemic drugs for moderate to severe psoriasis, the need to clarify patient candidates for systemic therapy has become very important. Here, we present a diagnostic algorithm and a formal measure, the Koo-Menter Psoriasis Instrument (KMPI), to aid in identifying patients that would benefit from systemic therapy. In addition, the KMPI can be used to document and justify treatment decisions for health care payers. While the decision to undertake systemic treatment and the choice of specific treatment plan must ultimately be made mutually by the patient and physician, these tools are designed to provide information that will be valuable in these determinations.

The relationships between objective and subjective ratings of disfigurement severity, and psychological adjustment

Although the role of the objectively and subjectively rated severity of appearance problems is often debated, the impact of severity upon psychological adjustment has yet to be explored fully. In this study, 400 patients with a range of physical differences in appearance were recruited through general plastic surgery outpatient clinics and waiting lists. Patients completed the Derriford Appearance Scale 24 (DAS24), a measure of psychological distress and behavioural dysfunction related to self-consciousness of appearance. Severity in the outpatient group was objectively rated by plastic surgeons, and severity amongst the waiting-list group was subjectively rated by the patients themselves. Multiple regression modelling demonstrated a linear relationship between subjective adjustment and severity, with greater perceived severity associated with poorer adjustment. Similar modelling demonstrated a weak but statistically significant quadratic relationship between objectively rated severity and adjustment for normally visible, but not for normally non-visible differences of appearance. Moderate, rather than mild or severe objective severity was most related to poor adjustment.

Psoriasis treatment: current and emerging directed therapies

Quality of life studies in patients with cutaneous psoriasis attest to its significant impact on day to day activities and personal social interactions. Up to 40% of patients with psoriasis may develop psoriatic arthritis, usually within 5-10 years after onset of the cutaneous disease, heightening quality of life issues. These data have prompted an increased awareness and interest in more aggressive management of psoriasis; coupled with a better understanding of immunopathogenesis, this has led to the development of new agents targeting specific cells and molecules involved in the development and maintenance of psoriatic plaques. Although non-biological therapies, including methotrexate and ciclosporin, show significant efficacy their side effect profiles have precluded their long term use for moderate to severe psoriasis. This review concentrates on new biological agents, focusing on the three agents approved for psoriasis within the past 18 months (alefacept, efalizumab, and etanercept). Phase II and III trial data on other agents in development (adalimumab and infliximab) are also presented. Surveys show many patients want to be treated more aggressively. It is hoped that the introduction of new agents that are more targeted and that hold the promise of fewer side effects will cause patients and their physicians to reconsider systemic treatment and, as a consequence, stimulate other patients to reconsider treatment for psoriasis. Close cooperation between dermatologists and rheumatologists, particularly in the area of psoriatic joint disease, will enhance these considerations.

Successful treatment of psoriasis improves psoriasis-specific but not more general aspects of patients' well-being

BACKGROUND

Psoriasis has a detrimental effect on patients' quality of life. However, there is a relative dearth of information on which aspects of a patient's well-being are affected by successful treatment.

OBJECTIVES

To investigate whether, and to what extent, improvement in the clinical severity of psoriasis induced by photochemotherapy with psoralen plus ultraviolet A (PUVA) translates into meaningful changes in beliefs about psoriasis, coping, stress, distress or disability.

METHODS

In a prospective study, 72 patients were assessed before PUVA therapy and again when they had achieved clearance of their psoriasis.

RESULTS

Patients demonstrated significant reductions in psoriasis-related disability, psoriasis-related stress or daily hassles and in the frequency of psoriasis-related symptoms. By comparison, there were no significant differences in levels of anxiety, depression or worrying. Similarly, patients' perceptions about cure, potential chronicity, causes, consequences and coping also remained unchanged.

CONCLUSIONS

These results suggest that while clearance of psoriasis produces a significant reduction in factors specific to psoriasis (disability and stress), it does not impact upon psychological distress, on patients' beliefs about psoriasis or on coping. This observation highlights the complex features of patients' psychological experience of psoriasis and may provide further impetus for integration of psychological interventions into standard care protocols.

Determinants of quality of life in patients with psoriasis: A study from the US population

BACKGROUND

Psoriasis is a common disease with substantial effects on quality of life. Few quality of life studies have been performed in psoriasis patients from the general US population.

OBJECTIVE

To describe the determinants of quality of life in psoriasis patients from the US population.

METHODS

Patients were randomly selected from the US population. Patients who identified themselves as having been diagnosed with psoriasis by a physician were invited to complete a more detailed survey about quality of life.

RESULTS

Two hundred sixty-six psoriasis patients from the US population completed the detailed survey. Body surface area showed the strongest association with decrements in quality of life (Spearman 0.50, P < .0001). Younger patients and female patients also had statistically significant reductions in quality of life. Increasing psoriasis severity was associated with seeking care from multiple physicians and having decrements in income.

CONCLUSION

Patients with more extensive skin involvement have greater reductions in quality of life. Female patients and young patients are affected to a greater extent.

Anger and acne: implications for quality of life, patient satisfaction and clinical care

BACKGROUND

Acne is a common skin disorder with a significant psychological and social impact for some people. Little is known about how personality and emotional traits affect acne and its impact on quality of life and treatment. Trait anger (TA), which is related to heart disease and other morbidities, may also affect acne and patients' adjustment to it.

OBJECTIVES

To evaluate the relationship between TA and acne severity, skin-related quality of life, satisfaction with treatment, and adherence to treatment.

PARTICIPANTS AND METHODS

A sample of 479 individuals with acne completed a survey instrument to assess acne severity, skin care practices, skin-related quality of life, satisfaction with treatment, adherence, TA and demographic variables. Respondents who reported high TA were compared with individuals with low TA on outcome variables. Regression analyses adjusted for covariates and identified the significant predictors of quality of life, satisfaction and adherence.

RESULTS

High TA was unrelated to acne severity (P = 0.2) or frequency of face washing (P = 0.9). Anger was significantly related to both global quality of life (P < 0.001) and skin-related quality of life (P = 0.002) as well as to satisfaction with treatment (P = 0.001) and adherence to treatment advice (P = 0.05) in bivariate analyses. Regression analyses revealed that high TA remained a significant predictor of global (P < 0.001) and skin-related quality of life (P = 0.003) and satisfaction with treatment (P = 0.04), but not adherence to treatment advice (P = 0.8) after controlling for covariates.

CONCLUSIONS

Anger is associated with the quality of patients' lives and with their satisfaction with treatment. Care of acne patients should include attention to anger and other chronic emotional states, quality of life, as well as to clinical severity. Simple guidelines are suggested for how clinicians might approach this important aspect of care.

Etanercept for the treatment of psoriasis and psoriatic arthritis

Etanercept is a fully human soluble recombinant p75 TNF receptor that blocks the binding of TNF to cell surface receptors, thereby neutralizing its biologic activity. Data supporting the FDA's approval of etanercept for controlling signs and symptoms and for inhibiting XRAY progression of psoriatic arthritis will be presented. Data supporting the FDA filing of etanercept for the treatment of moderate to severe psoriasis will also be presented. Long term safety data of etanercept in the over 231,000 adults and children with rheumatoid arthritis who have been treated worldwide will be briefly summarized.

Divergent Beliefs About Psoriasis Are Associated with Increased Psychological Distress

The psychological adjustment of patients with psoriasis has been studied extensively. By comparison, no research has focused on their partners. We examined illness representations of psoriasis held by patients and their partners, and investigated whether divergent beliefs were associated with psychological distress. Fifty-eight patients with chronic plaque psoriasis and their partners completed a range of psychological assessments including beliefs about the condition, anxiety, depression, and worry. Patients also completed a self-assessment of psoriasis severity. Patients with psoriasis had significantly higher levels of anxiety, depression, and worry than their partners (t's > 2.53, p's < .05). Multiple regression analysis indicated that divergence in patients' and partners' beliefs about emotional impact of psoriasis and chronicity of timeline accounted for a statistically significant (21.3%) proportion of the variance in depression for partners. Differences in views on the consequences of having psoriasis and the cyclical nature of the condition were also significantly associated with increased levels of worry in partners. Dissimilarity in particular aspects of illness representations are associated with increased psychological distress in particular for the partners of patients with psoriasis. The results illustrate the importance of concordance between patients' and partners' models of illness in relation to adjustment, and highlight the need to consider and collaborate with both patients and their partners in managing this challenging condition.

Quantitative evaluation of severity in psoriatic lesions using three-dimensional morphometry

The severity of psoriasis has been traditionally assessed by measures, such as the psoriasis area and severity index (PASI), the psoriasis severity scores, and the lesional severity scores. As a result, even experienced dermatologists show variations when attempting to determine the severity of psoriasis. Therefore, a better non-invasive and objective measurement of clinical signs is needed. In this study, an instrument, a so-called 'stereoimage optical topometer' (SOT), based on a new concept of 'stereoimaging' was used to measure the three-dimensional skin surface. The aim of this study was to compare the results obtained by the SOT with the visual score of psoriasis lesion. Thirty psoriatic patients were enrolled in this study. Initially, the severity of the infiltration and the scale of 134 psoriatic lesions were assessed by using a visual scoring system (0: none, 1: mild, 2: moderate, 3: severe, and 4: very severe), as scored by five dermatologists. The SOT was then used to quantify the severity of each psoriatic lesion using four three-dimensional SOT parameters (Sa, SL, SA, and SV). Secondly, the involved skin-surface area in the psoriasis cases was scored by the naked eye by the five dermatologists and by image analysis. Statistically significant differences were observed between grades 0, 1, 2, and 3 in terms of the severity measurements of the individual psoriatic lesions by SOT when using the parameters Sa, SL, SA, and SV. Therefore, it was concluded that there is a strong correlation between the results measured by visual scoring and by SOT in psoriasis.