Psoriasis uncovered--measuring burden of disease impact in a survey of Australians with psoriasis

Australian consensus: Treatment goals for moderate to severe psoriasis in the era of targeted therapies - Adult patients

BACKGROUND

Over the last decade, the treatment landscape for moderate-severe psoriasis has rapidly evolved. The Australasian College of Dermatologists sought to review and update previously published treatment goals for moderate-severe psoriasis.

METHODS

A modified Delphi approach was used. Comprehensive literature review and guideline evaluation resulted in the development of statements and other questions to establish current clinical practices. Two rounds of anonymous voting were undertaken, with a collaborative meeting held in between to discuss areas of discordance. Overall, consensus was defined as achievement of ≥75% agreement in the range 7-9 on a 9-point scale (1 strongly disagree; 9 strongly agree).

RESULTS

Consensus was achieved on 26/29 statements in round 1 and a further 20 statements in round 2. There was strong agreement to expanding the classification/definition of psoriasis severity by including a choice of metrics, incorporating quality of life measures, and widening the scope of high-impact sites. Consensus was also reached on revised treatment response criteria, which were then incorporated into a new treatment algorithm. There was discordance with the current requirement to undertake a trial with established systemic agents before accessing targeted therapy.

CONCLUSION

The ability of new targeted treatment options to change the narrative in psoriasis patient care can only be properly realised if challenges to timely and equitable access are addressed. The proposed framework for the assessment, classification and management of moderate-severe psoriasis aligns with international recommendations. Its adoption into Australian clinical practice is hoped to improve treatment outcomes and patients' satisfaction with their care.

Dermatology Life Quality Index in Patients with Psoriasis Treated with Biologic Versus Non-biologic Treatment in Malaysia: A Retrospective Cross-Sectional Study

BACKGROUND

Psoriasis imposes a substantial burden on patients' social, emotional, physical, and family life. Although psoriasis has no complete cure, various treatments are available to control its symptoms and improve a patients' quality of life.

OBJECTIVE

We aimed to compare the effectiveness of biologic versus non-biologic treatments on health-related quality of life among patients with psoriasis in Malaysia.

METHODS

This retrospective cross-sectional study evaluated data of adult patients diagnosed with psoriasis during 2007-18 from the Malaysian Psoriasis Registry. Baseline demographics, disease, and treatment characteristics were described. For a subset of patients treated with biologics and non-biologics who had baseline and 6-month follow-up data available, changes in the mean Dermatology Life Quality Index scores and the proportion of patients with a clinically relevant improvement (≥ 4 points) post-treatment were assessed.

RESULTS

Overall, 15,238 adult patients with psoriasis from the Malaysian Psoriasis Registry were included in the analysis. Patients receiving biologics showed a statistically significant reduction in the mean Dermatology Life Quality Index scores after 6 months compared with those receiving non-biologic treatment (- 5.7 vs - 0.8%; p < 0.001). The proportion of patients who achieved a ≥ 4-point improvement in Dermatology Life Quality Index scores was approximately two times greater in the biologic-treated group versus the non-biologic-treated group (56.4 vs 27.7%).

CONCLUSIONS

Biologic treatment showed a greater reduction in the Dermatology Life Quality Index scores of patients with psoriasis versus non-biologic treatment. These results highlight the importance of early treatment with more efficacious treatment options, such as biologic therapies, to improve the overall health-related quality of life of patients with psoriasis.

Identifying and managing psoriasis-associated comorbidities: the IMPACT research programme

Background

Psoriasis is a common, lifelong inflammatory skin disease, the severity of which can range from limited disease involving a small body surface area to extensive skin involvement. It is associated with high levels of physical and psychosocial disability and a range of comorbidities, including cardiovascular disease, and it is currently incurable.

Objectives

To (1) confirm which patients with psoriasis are at highest risk of developing additional long-term conditions and identify service use and costs to patient, (2) apply knowledge about risk of comorbid disease to the development of targeted screening services to reduce risk of further disease, (3) learn how patients with psoriasis cope with their condition and about their views of service provision, (4) identify the barriers to provision of best care for patients with psoriasis and (5) develop patient self-management resources and staff training packages to improve the lives of people with psoriasis.

Design

Mixed methods including two systematic reviews, one population cohort study, one primary care screening study, one discrete choice study, four qualitative studies and three mixed-methodology studies.

Setting

Primary care, secondary care and online surveys.

Participants

People with psoriasis and health-care professionals who manage patients with psoriasis.

Results

Prevalence rates for psoriasis vary by geographical location. Incidence in the UK was estimated to be between 1.30% and 2.60%. Knowledge about the cost-effectiveness of therapies is limited because high-quality clinical comparisons of interventions have not been done or involve short-term follow-up. After adjusting for known cardiovascular risk factors, psoriasis (including severe forms) was not found to be an independent risk factor for major cardiovascular events; however, co-occurrence of inflammatory arthritis was a risk factor. Traditional risk factors were high in patients with psoriasis. Large numbers of patients with suboptimal management of known risk factors were found by screening patients in primary care. Risk information was seldom discussed with patients as part of screening consultations, meaning that a traditional screening approach may not be effective in reducing comorbidities associated with psoriasis. Gaps in training of health-care practitioners to manage psoriasis effectively were identified, including knowledge about risk factors for comorbidities and methods of facilitating behavioural change. Theory-based, high-design-quality patient materials broadened patient understanding of psoriasis and self-management. A 1-day training course based on motivational interviewing principles was effective in increasing practitioner knowledge and changing consultation styles. The primary economic analysis indicated a high level of uncertainty. Sensitivity analysis indicated some situations when the interventions may be cost-effective. The interventions need to be assessed for long-term (cost-)effectiveness.

Limitations

The duration of patient follow-up in the study of cardiovascular disease was relatively short; as a result, future studies with longer follow-up are recommended.

Conclusions

Recognition of the nature of the psoriasis and its impact, knowledge of best practice and guideline use are all limited in those most likely to provide care for the majority of patients. Patients and practitioners are likely to benefit from the provision of appropriate support and/or training that broadens understanding of psoriasis as a complex condition and incorporates support for appropriate health behaviour change. Both interventions were feasible and acceptable to patients and practitioners. Cost-effectiveness remains to be explored.

Future work

Patient support materials have been created for patients and NHS providers. A 1-day training programme with training materials for dermatologists, specialist nurses and primary care practitioners has been designed. Spin-off research projects include a national study of responses to psoriasis therapy and a global study of the prevalence and incidence of psoriasis. A new clinical service is being developed locally based on the key findings of the Identification and Management of Psoriasis Associated ComorbidiTy (IMPACT) programme.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 10, No. 3. See the NIHR Journals Library website for further project information.

Burden of Disease for Psoriasis in Argentina, Brazil, Colombia, and Mexico

OBJECTIVES

Psoriasis (PsO) is a chronic, inflammatory, multisystem disease with predominantly skin and joint manifestations. The disease is also associated with lower quality of life, lower work productivity, and higher healthcare costs. The objective of this study was to conduct a systematic literature review of the disease burden for PsO in Argentina, Brazil, Colombia, and Mexico.

METHODS

PubMed/MEDLINE, Web of Science, SciELO, and LILACS were searched for publications in English, Spanish, or Portuguese from 2003 to July 2018.

RESULTS

A total of 680 records were retrieved and 13 articles were included. In Latin America, PsO has a negative impact on the physical and mental well-being as shown by substantially lower scores on measures of quality of life (eg, 12-item Short-Form Health Survey) for patients than the general population. Patients with PsO reported higher levels of presenteeism, activity impairment, and work productivity loss. The estimated annual costs per patient with PsO in Colombia were $3497.58 and $2160.92 for the private sector and public scenario, respectively.

CONCLUSIONS

Although evidence on the full cost and impact of PsO in Latin America is scarce and further research is needed, the burden in these regions is significant and comparable with that in other parts of the world.

Enhancing self-compassion in individuals with visible skin conditions: randomised pilot of the 'My Changed Body' self-compassion writing intervention

Background: Abnormalities in the appearance of skin are commonly associated with compromised self-body perceptions, arising from physical manifestations of the skin condition that deviate from the individual's idealised body image. These body image concerns are associated with a range of psychological issues including anxiety, depression, fear of negative evaluation, and suicidal ideation. Unfortunately, stigma and embarrassment associated with these body image concerns mean that these issues are rarely discussed in clinical medical consultations. There is thus a need for highly accessible and acceptable interventions to address skin-related body image concerns. We have previously demonstrated that a web-based self-compassion focused therapeutic writing approach, the 'My Changed Body' intervention, is efficacious in addressing body image concerns of women in the breast cancer context. The aim of this experimental pilot study was to investigate the feasibility of applying the My Changed Body intervention to address visible skin-related body image concerns. Methods: Participants (N = 50) with a range of visible skin conditions provided online informed consent, then completed measures of demographic and medical history, body image disturbance, self-compassion and positive and negative affect. They were then randomly allocated either to an active control expressive writing condition (n = 25) or to the My Changed Body writing condition (n = 25). Participants were blind to their condition allocation. Immediately after completing their allocated writing exercise, participants completed self-compassion and affect measures. Results: Controlling for pre-writing body image disturbance, repeated measures ANCOVAs with fixed effects revealed that self-compassion and negative affect significantly improved after the My Changed Body writing exercise, compared to the control condition. There was no between groups difference at follow-up in positive affect. Conclusions: This study suggests that the My Changed Body writing intervention may provide benefit to individuals with visible skin conditions. A randomised controlled trial is needed to further confirm these results.

Patient Perspectives on the Challenges and Responsibilities of Living With Chronic Inflammatory Diseases: Qualitative Study

Background

Collectively, chronic inflammatory diseases take a great toll on individuals and society in terms of participation restrictions, quality of life, and economic costs. Although prior qualitative studies have reported patients’ experiences and challenges living with specific diseases, few have compared the consequences of disease management in daily life across different types of inflammatory diseases in studies led by patient partners.

Objective

The aim of this study was to identify the significant consequences of inflammatory arthritis, psoriasis, and inflammatory bowel diseases on daily life and explore commonalities across diseases.

Methods

A cross-sectional Web-based survey was designed by patient research partners and distributed by patient awareness organizations via their social media channels and by sharing a link in a newspaper story. One open-ended item asked about burdens and responsibilities experienced in daily life. Informed by narrative traditions in qualitative health research, we applied a thematic content analysis to participants’ written accounts in response to this item. This is an example of a study conceived, conducted, and interpreted with patients as research partners.

Results

A total of 636 Canadians, with a median age band of 55-64 years, submitted surveys, and 80% of the respondents were women. Moreover, 540 participants provided written substantive responses to the open-ended item. Overall, 4 main narratives were generated: (1) daily life disrupted; (2) socioeconomic vulnerabilities; (3) stresses around visible, invisible, and hiding disabilities; and (4) actions aimed at staying positive. Ways in which participants experienced social stigma, pain and fatigue, balancing responsibilities, and worries about the future appeared throughout all 4 narratives.

Conclusions

People living with chronic inflammatory diseases affecting joints, skin, and the digestive tract report important gaps between health, social, and economic support systems that create barriers to finding the services they need to sustain their health. Regardless of diagnosis, they report similar experiences navigating the consequences of lifelong conditions, which have implications for policy makers. There is a need for outcome measures in research and service delivery to address patient priorities and for programs to fill gaps created by the artificial administrative separation of health services, social services, and income assistance.

Patient perceptions of clear/almost clear skin in moderate-to-severe plaque psoriasis: results of the Clear About Psoriasis worldwide survey

BACKGROUND

Therapeutic advances have made the achievement of clear/almost clear skin possible for many patients with moderate-to-severe plaque psoriasis.

OBJECTIVE

To determine patient perceptions of the impact of psoriasis and of attaining clear/almost clear skin.

METHODS

Global survey of patients with moderate-to-severe psoriasis.

RESULTS

A total of 8338 patients from 31 countries participated. The majority (57%) had not achieved self-assessed clear/almost clear skin with their current therapy, and 56% of those who had not met this goal believed it would be impossible to do so. Among the patients who had clear/almost clear skin, 73% had not initiated their current treatment until >1 year after psoriasis diagnosis, and 28% had to wait >5 years. Eighty-four percent of all respondents experienced discrimination and/or humiliation due to psoriasis, and many reported negative effects on work, intimate relationships, sleep and mental health. Patients without clear/almost clear skin reported that such achievement would open new possibilities, such as swimming (58%), a wider choice of clothing (40%), and meeting new people (26%). A limitation of this study, as with any survey-based research, is that selection and recall bias may have been present. Additionally, respondent definitions of clear/almost clear skin were subjective and may have varied.

CONCLUSION

Despite the importance of clear/almost clear skin to psoriasis patients, most are still not achieving it, and many are unaware it is possible.

'New to me': changing patient understanding of psoriasis and identifying mechanisms of change. The Pso Well® patient materials mixed-methods feasibility study

Background

Psoriasis is an inflammatory long‐term condition involving comorbidities, unhealthy lifestyle and significant life impact. Patients’ understanding of psoriasis is limited and support lacking. The Common‐Sense Model of Self‐Regulation of Health and Illness emphasizes the role of illness and treatment beliefs on coping and self‐management. New ‘Pso Well^®’ patient materials informed by the model, addressed psoriasis as a long‐term condition, medication management and lifestyle behaviours.

Objectives

To investigate whether Pso Well^® materials (i) broaden understanding of psoriasis without increasing anxiety; (ii) are acceptable; and (iii) comprise features that appear to effect change.

Methods

The Revised Illness Perceptions Questionnaire (IPQ‐R modified) and the Hospital Anxiety and Depression Scale (HADS) were administered in patients before and after intervention. Numerical rating scales assessed perceptions of change in understanding and anxiety resulting from engagement with the materials. Qualitative interviews explored acceptability and perceived ‘active ingredients’.

Results

Fifty‐five patients completed pre‐ and postintervention questionnaires (56% female; median age 59 years). Postintervention, a large effect size was indicated in two IPQ‐R domains – illness coherence [t(55) = −3·48, P = 0·001 (two‐tailed), η² = 0·19] and personal control [t(55) = −2·98, P = 0·004 (two‐tailed), η² = 0·14] – and a medium effect in one, treatment control [t(55) = −2·08, P = 0·042 (two‐tailed), η² = 0·08]. HADS scores did not change. For numerical rating scales, 80% of participants reported increased understanding of psoriasis and none reported increased anxiety. Interviews with 19 patients indicated the materials were acceptable and usable. Factors reported to broaden understanding and promote engagement with self‐management included linking of related disease aspects, personally relevant content and high‐quality design.

Conclusions

High‐quality, theory‐based psoriasis materials are acceptable to patients and can improve understanding and sense of control without increasing anxiety.

What's already known about this topic?

Psoriasis is associated with comorbidities, unhealthy lifestyle and significant life impact.

Patients’ understanding of psoriasis is limited, self‐management support is lacking and disengagement from healthcare services is common.

What does this study add?

The new, theory‐informed Pso Well^® patient materials address psoriasis as a long‐term condition; medications management and lifestyle behaviour.

The Pso Well^® patient materials can increase understanding of psoriasis, promote feelings of self‐worth and encourage a desire to engage in self‐management and behaviour change, without increasing anxiety or depression.

What are the clinical implications of this work?

The Pso Well^® patient materials could support clinical consultations by helping patients recognize the remitting–relapsing nature of psoriasis.

This will help to improve understanding of the disease, as well as providing a clearer rationale for treatment adherence and lifestyle behaviour change.

Linked Comment: Prinsen. Br J Dermatol 2017; 177:616–617

The challenges of assessing patients' medication beliefs: a qualitative study

Background

An estimated 50% of patients do not take their medication as prescribed, with medication adherence associated with adverse outcomes and higher costs of care. The Necessity-Concerns Framework identified individual’s beliefs about their medication as playing a key role in adherence, and UK Clinical Adherence Guidelines recommend eliciting and incorporating individual’s perceptions of their medication within the consultation. The Beliefs about Medicines Questionnaire (BMQ) is widely used to assess medication beliefs, however, given the condition-specific nature of some self-management regimens, it is unknown whether this tool is able to fully capture beliefs about more complex medication regimens.

Methods

We examined the challenges of assessing medication beliefs using the BMQ in 20 people with a complex relapsing-remitting condition recruited from community sources. Data were collected from people with psoriasis; a patient group characterised by complex medication regimens, which include therapies that are applied topically, phototherapy/photochemotherapy, and therapies that are administered orally or via subcutaneous or intravenous injections. Semi-structured cognitive interviews were undertaken, with responses coded using established schedules and analysed using Content analysis.

Results

Individual’s beliefs about their condition specific therapies were not accurately captured by the BMQ. Medication beliefs as expressed during ‘real-time’ completion of the BMQ were underestimated, or failed to be captured, by the corresponding scores given by participants.

There was mismatch between the terminology used in the scale and individuals perceptions of their condition and the complexity of its management and treatment outcomes. Currently the BMQ cannot represent beliefs about medicines underuse, even though some individuals with psoriasis viewed access to therapies as overly restrictive. Some the BMQ items were misinterpreted in part due to ambiguous item wording or due to misreading by participants.

Conclusions

This is the first study to identify general and condition-specific difficulties experienced by individuals completing the BMQ in ‘real time’. The main implication of this research is the need to develop condition-specific versions of the BMQ in order that this important instrument can capture the full range of medication beliefs in individuals living with a complex relapsing-remitting condition. Access to condition-specific versions could significantly increase our understanding of beliefs which facilitate or reduce medication adherence.

Nonadherence to psoriasis medication as an outcome of limited coping resources and conflicting goals: findings from a qualitative interview study with people with psoriasis

Background

Medication nonadherence is known to limit the effectiveness of available therapies; however, little is known specifically about medication adherence in people with psoriasis. Medicines self‐management can feel onerous to those with dermatological conditions due to the nature of therapies prescribed and many individuals with psoriasis experience additional challenges such as physical and psychological comorbidities that place significant additional demands on individuals and may undermine adherence. Viewing nonadherence to medication as an outcome of limited personal coping resources and conflicting goals may help to explain medication nonadherence.

Objectives

To explore individuals’ perspectives of their psoriasis, medication and its management.

Methods

Twenty people with psoriasis were recruited from community samples in England and interviewed in‐depth about their perceptions of their psoriasis, medication, and adherence to medication and self‐management advice. Data were analysed using Framework Analysis.

Results

Participants reported that adhering to recommended treatment regimens conflicted with the management of the physical and psychological demands of living with psoriasis. Medication usage was viewed as a source of unresolved emotional distress and, for some, resulted in poor self‐reported adherence, which included medication overuse, underuse and rejection of prescribed therapies. Perceived lack of engagement by clinicians with participants’ self‐management difficulties was viewed as an additional source of stress and distress.

Conclusions

Adhering to medication in psoriasis can be an additional source of considerable emotional distress. We interpreted some episodes of nonadherence to psoriasis medication as rational attempts by individuals to minimize distress and to gain control over their life.

What's already known about this topic?

Although common, little is known about factors contributing to nonadherence to therapies used in psoriasis.

What does this study add?

Illness and medication beliefs and associated mood influence medication nonadherence.

Attempts to adhere can undermine people's ability to manage their emotional distress.

For some patients, following prescribed medication regimens adds to rather than relieves psoriasis‐associated distress.

What are the clinical implications of this work?

Some occurrences of nonadherence to medication in psoriasis should be recognized as a strategic decision by the patient to reduce distress and to gain control.

Assessing patients’ beliefs and mood, and identifying potentially conflicting health goals may help to support medication adherence.

Mapping the Effect of Psoriatic Arthritis Using the International Classification of Functioning, Disability and Health

Objective.

The effect of a disease can be categorized by a standardized reference system: the International Classification of Functioning, Disability and Health (ICF). The objective was to map the effect of psoriatic arthritis (PsA) from the patient’s perspective to the ICF.

Methods.

A systematic literature review was performed. Qualitative publications reporting domains of impact important for patients with PsA were identified using the following terms: (“psoriatic arthritis”) AND (“quality of life” OR “impact”). Meaningful concepts were extracted from the publications, grouped into domains and linked to the ICF categories. The number of concepts linked to each ICF category and to each ICF level was calculated. The number of concepts not linkable was also calculated.

Results.

Eleven studies (13 articles) were included in the analysis. Twenty-five domains of impact were cited, of which the ability to work/volunteer and social participation were the most cited (both by 10 studies). In total, 258 concepts were identified, of which 217 could be linked to 136 different ICF categories; 41 concepts, mostly personal factors, could not be precisely linked. The most represented ICF component was activities and participation (42.6%) rather than body structures (10.3%) or body functions (29.4%). Ten studies (90.9%) reported impairments in the ability to work/volunteer and social participation, and 7 (63.6%) reported leisure activities, family and intimacy, pain, skin problems, and body image.

Conclusion.

PsA widely affects all aspects of patients’ lives, in particular aspects related to activities and participation. The ICF is a useful approach for the classification of disease effect.

'I should have taken that further' - missed opportunities during cardiovascular risk assessment in patients with psoriasis in UK primary care settings: a mixed-methods study

BACKGROUND

Unhealthy lifestyle is common in psoriasis, contributing to worsening disease and increased cardiovascular disease (CVD) risk. CVD risk communication should improve patients' understanding of risk and risk-reducing behaviours; however, the effectiveness of risk screening is debated and evaluation currently limited.

OBJECTIVE

To examine the process of assessing for and communicating about CVD risk in the context of psoriasis.

DESIGN

Mixed-methods study in English general practices to (i) determine proportions of CVD risk factors among patients with psoriasis at risk assessment and (ii) examine patient and practitioner experiences of risk communication to identify salient 'process' issues. Audio recordings of consultations informed in-depth interviews with patients and practitioners using tape-assisted recall, analysed with framework analysis.

PARTICIPANTS

Patients with psoriasis (n = 287) undergoing CVD risk assessment; 29 patients and 12 practitioners interviewed.

RESULTS

A high proportion of patients had risk factor levels apparent at risk assessment above NICE recommendations: very high waist circumference (52%), obesity (35%), raised blood pressure (29%), smoking (18%) and excess alcohol consumption (18%). There was little evidence of personalized discussion about CVD risk and behaviour change support in consultations. Professionals reported a lack of training in behaviour change, while patients wanted to discuss CVD risk/risk reduction and believed practitioners to be influential in supporting lifestyle management.

CONCLUSIONS

Despite high levels of risk factors identified, opportunities may be missed in consultations to support patients with psoriasis to understand CVD risk/risk reduction. Practitioners need training in behaviour change techniques to capitalize on 'teachable moments' and increase the effectiveness of risk screening.

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.

Discovery in genetic skin disease: the impact of high throughput genetic technologies

The last decade has seen considerable advances in our understanding of the genetic basis of skin disease, as a consequence of high throughput sequencing technologies including next generation sequencing and whole exome sequencing. We have now determined the genes underlying several monogenic diseases, such as harlequin ichthyosis, Olmsted syndrome, and exfoliative ichthyosis, which have provided unique insights into the structure and function of the skin. In addition, through genome wide association studies we now have an understanding of how low penetrance variants contribute to inflammatory skin diseases such as psoriasis vulgaris and atopic dermatitis, and how they contribute to underlying pathophysiological disease processes. In this review we discuss strategies used to unravel the genes underlying both monogenic and complex trait skin diseases in the last 10 years and the implications on mechanistic studies, diagnostics, and therapeutics.