Health-related quality of life in adolescents with psoriasis: an interview-based study

Psoriasis and mental health in adolescents: A cross-sectional study within the Danish National Birth Cohort

BACKGROUND

Psoriasis is a chronic skin disease associated with lower quality of life and higher risk of anxiety and depression in adults. We investigate whether adolescents with psoriasis also experience poorer mental health than their peers.

METHODS

In this cross-sectional study, we included questionnaire data on psoriasis and mental health from the 18-year follow-up of the Danish National Birth Cohort. We estimated odds ratios (OR) and 95 % confidence intervals (CI) using a logistic regression with inverse probability weighting to account for potential selection bias, adjusted for potential confounders identified a priori. We estimated associations between self-reported psoriasis and multiple aspects of mental health (self-rated health, life satisfaction, mental well-being, loneliness, overall and internalizing behavioral difficulties, depressive symptoms, and anxiety symptoms). In sensitivity analyses, we examined doctor-diagnosed psoriasis and psoriasis with and without joint pain.

RESULTS

Of the 44,838 included in this study, 1147 (2.6 %) reported psoriasis. Adolescents with psoriasis had a higher risk of nearly all outcomes, including depressive symptoms (OR 1.38; 1.19-1.58) and panic/agoraphobia among both males (OR 1.72; 1.33-2.19) and females (OR 1.60; 1.33-1.92). Associations attenuated when restricted to doctor-diagnosed psoriasis. Associations with poor mental health were mainly observed for adolescents with psoriasis also reporting joint pain.

LIMITATIONS

We could not establish temporality and lacked data on joint pain in referents.

CONCLUSION

Psoriasis is associated with poor mental health in adolescents. This appears to be driven by adolescents with psoriasis also reporting joint pain and is less evident in those with a doctor-confirmed diagnosis.

Treatment Preferences in Young Adults with Moderate to Severe Psoriasis: A Qualitative Study from the Nordic Countries

INTRODUCTION

The purpose of this study is to explore treatment preferences and identify patient characteristics in young bio-naive adults with moderate to severe psoriasis in the Nordic countries (Norway, Finland, Sweden, and Denmark).

METHODS

Patients were 18-45 years old and bio-naive but referred for biologic treatment of moderate to severe psoriasis. Patients were included at eight Nordic dermatology clinics. Patients with significant comorbidity or psoriatic arthritis were excluded. The Psoriasis Area and Severity Index (PASI) and Dermatology Life Quality Index (DLQI) were assessed along with basic patient information. A semistructured interview guide was used in individual qualitative interviews, asking patients about their treatment preferences and reasons, disease journey, and disease management. The interviews were analyzed using thematic content analysis. Twenty-four patients sufficed to reach saturation in this qualitative study.

RESULTS

The patient sample characteristics represented a qualitative variation in age, sex, symptoms, duration of disease, and country. We included a total of 12 male and 12 female patients. The mean age was 34 years (range 18-45 years), the mean age at diagnosis was 20 years (range 6-34 years), the mean ± standard deviation (SD) time since diagnosis was 13 ± 8 years, PASI was 9.5 ± 4.7, and DLQI was 15.2 ± 6.4. Interviews suggested that both the burden of disease as well as the burden of treatment influenced patient preferences regarding treatment attributes, hence getting alleviation from symptoms did not alone influence patient preferences. Time, effort, and inconvenience related to psoriasis treatments also influenced patient preferences.

CONCLUSIONS

This first in-depth, qualitative study in young bio-naive adults with psoriasis suggests that patient preferences are focusing not only on symptom relief but also on alleviating the burden of psoriasis treatment. Understanding the reasons for patient preferences and the perspectives of young adults is needed to guide individual shared decision-making in psoriasis management.

Manifestation of anxiety and depression among pediatric patients with psoriasis: A review

Psoriasis is a chronic, inflammatory skin disorder with manifestations extending beyond visual presentation to encompass psychological burden. Though the association between psoriasis and mental health disorders in adults is widely accepted, there is inadequate research to generalize these findings to pediatric populations. In this review of the literature, we discuss the prevalence of anxiety and depression among pediatric patients with psoriasis in hopes of raising awareness of these associations and advocating for psychological screening and intervention in dermatology practice.

Mindful parenting intervention for parents of children with skin conditions: a single group experimental cases series

BACKGROUND

Parents of children with eczema or psoriasis experience high levels of parenting stress, which can negatively impact their child's mental and physical health.

AIMS

We aimed to investigate the effectiveness, feasibility and acceptability of a mindful parenting intervention for parents of children with eczema or psoriasis.

METHOD

Seven parents of children (4-12 years old) with eczema or psoriasis took part in an 8-week mindful parenting group intervention. A single-case experimental design was adopted, whereby parents completed daily idiographic measures of parenting stress related to their child's skin condition. Parents also completed standardised questionnaires measuring their parenting stress, depression, anxiety and quality of life, and children completed a quality of life measure, at four time points: baseline, pre-intervention, post-intervention and 6-week follow-up. Parents provided qualitative feedback after the intervention.

RESULTS

All parents completed the intervention and showed improvements in idiographic measures of parenting stress from baseline to follow-up. Improvements in parenting stress were larger at follow-up than post-intervention, suggesting the benefits of intervention continue beyond the intervention. Six of seven parent-child dyads showed improvement in at least one of the wellbeing measures, from pre-intervention to post-intervention or follow-up. Feasibility was demonstrated through good participant retention, adherence to home practice, and treatment fidelity. Acceptability was demonstrated through positive parent evaluations of the intervention.

CONCLUSIONS

Mindful parenting can be an effective, feasible and acceptable intervention for parents of children with eczema or psoriasis. Future studies should attempt to replicate the findings through randomised controlled trials.

The Brain-Skin Axis in Psoriasis-Psychological, Psychiatric, Hormonal, and Dermatological Aspects

Psoriasis is a chronic inflammatory skin disease with systemic manifestation, in which psychological factors play an important role. The etiology of psoriasis is complex and multifactorial, including genetic background and environmental factors such as emotional or physical stress. Psychological stress may also play a role in exacerbation of psoriasis, by dysregulation of the hypothalamic–pituitary–adrenal (HPA) axis, sympathetic–adrenal–medullary axis, peripheral nervous system, and immune system. Skin cells also express various neuropeptides and hormones in response to stress, including the fully functional analog of the HPA axis. The deterioration of psoriatic lesions is accompanied by increased production of inflammatory mediators, which could contribute to the imbalance of neurotransmitters and the development of symptoms of depression and anxiety. Therefore, deregulation of the crosstalk between endocrine, paracrine, and autocrine stress signaling pathways contributes to clinical manifestations of psoriasis, which requires multidisciplinary approaches.

Does the lifestyle of patients with psoriasis affect their illness?

Psoriasis is one of the most common chronic, incurable inflammatory skin diseases, affecting 2–4% of the general population. Etiopathogenesis of this disease remains unclear. It is widely considered to be a multifactorial disorder caused by the interaction between inherited susceptibility alleles and environmental risk factors, such as lifestyle, diet, stimulants, foci of inflammation, and psychological factors. The widespread prevalence of psoriasis is a very significant health and socioeconomic problem. Treatment of psoriasis is based on relieving the acute symptoms of the disease. Despite the implementation of many therapeutic options, including biological treatment, effectiveness of these options is not always sufficient, or in some patients it is not satisfactory. In order to properly control the symptoms of the disease, the patient should be told that the therapeutic effect is achieved not only by pharmacotherapy but also by introducing appropriate healthy habits in everyday life. This article discusses the importance of patient-controlled factors that affect the severity of psoriasis. Theimportance of regular exercise, smoking avoidance, and reduced alcohol consumption is explained, as well as the importance for psoriasis treatment of psychotherapy and spa therapy. Understanding the essence of these factors in the treatment of psoriasis is important in achieving satisfactory therapeutic effects.

Treatment goals and preferences of pediatric psoriasis patients, young adults, and parents

BACKGROUND

Treatment needs of young psoriasis patients and parents are not widely studied and could advance patient-centered care.

OBJECTIVE

To explore treatment goals and preferences of pediatric psoriasis patients, young adults, and parents.

METHODS

A web-based survey among Dutch psoriasis patients aged ≥6 to ≤30 years and parents included multiple-choice, open-ended, and 4-point Likert scale questions. Treatment goals and characteristic preferences of pediatric patients (≤17 years) were compared to young adults (≥18 years) and parents.

RESULTS

195 young patients (20.2 ± 6.3 years) and 45 parents were included. The most important treatment goals were 'preventing lesions', 'reducing lesions', 'no itch', and 'no lesions'. Regarding treatment characteristics, 'long-term safety', 'high effectiveness', and 'short-term safety' were most important. We found differences by age, gender, and current treatment. Pediatric patients rated 'not sticky', 'quick results', and 'no/few blood samples needed' higher than parents and/or young adults. Young adults rated 'feeling more confident' and 'better quality of sleep' higher than pediatric patients. Parents considered safety most important. Psychosocial goals were more important for women and patients on biologics.

CONCLUSION

Young psoriasis patients and parents mainly strive to clear lesions and itch with effective and safe treatment. However, revealed differences underline the relevance of addressing individual needs.

Ixekizumab for the treatment of pediatric patients with moderate to severe plaque psoriasis

Introduction: Ixekizumab (IXE), a high affinity humanized monoclonal antibody that selectively targets interleukin-17A, is approved in the United States (US) and the European Union (EU) for pediatric patients with moderate to severe plaque psoriasis. This review summarizes ixekizumab use in the phase 3, randomized, double-blind, placebo-controlled study in pediatric patients with moderate to severe plaque psoriasis and provides some clinical pearls we have learned after using the drug in the pediatric population for the past 3 years.Areas covered: Review of IXORA-PEDS trial data, general literature review pertaining to the systemic treatment of pediatric psoriasis as well as our clinical experience with IXEExpert opinion: IXE is the only IL17 antagonist for pediatric psoriasis and is a welcome addition to our armamentarium.

Factors influencing quality of life in children with low-flow vascular malformations: a qualitative study using focus groups

BACKGROUND

Very few studies have evaluated the quality of life (QoL) of children suffering from low-flow vascular malformations. This is the first study investigating the influencing factors.

OBJECTIVES

To identify the factors influencing QoL in children with low-flow vascular malformations.

METHODS

We conducted a qualitative study employing focus group interviews (Clinical Trials Number: NCT03440827). The study was a prospective, interventional, non-comparative, multicentre study performed in four expert centres for vascular anomalies. Qualitative data about personal experiences, feelings, difficulties, needs and various factors influencing behaviours were collected. Theme-based content analysis (manual and specialist textural software guided) were used to analyse the verbatim transcripts of all focus group sessions. Manual qualitative discourse analysis was performed to identify the different themes and categories. Informatics' analyses were subsequently performed for each individual category.

RESULTS

Ten focus groups (26 individuals including 10 children aged 11 to 15 years) were conducted until saturation. Influencing factors were related to 4 categories: medical care, self-image, social impact on daily activities and challenging social relationships. These factors were responsible for intrafamily upheavals and may lead to future identity-building problems.

CONCLUSIONS

This study provides an essential framework from which physicians can develop strategies to improve patient care and quality of life. These data may also be useful to develop specific age-sensitive QoL questionnaires.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Quality of Life and Disease Impact of Atopic Dermatitis and Psoriasis on Children and Their Families

Atopic dermatitis (AD) and psoriasis are common chronic skin diseases affecting children. These disorders negatively impact the quality of life (QoL) of patients in health-related aspects such as physical, psychosocial, and mental functioning. This health impact is more accurately represented when accounting for the numerous comorbidities associated with each disorder, and the impact the disorders have on patients’ families. A number of QoL tools have been developed and can be routinely implemented in the evaluation of QoL in pediatric patients and their caregivers. Ways to improve QoL include a multidisciplinary approach to care, education, and psychological support.

Development and preliminary validation of the Adolescent Psoriasis Quality of Life instrument: a disease-specific measure of quality of life in adolescents with psoriasis

Background

No age‐appropriate and disease‐specific instrument currently exists to measure health‐related quality of life in adolescents with psoriasis (patients aged 12–17 years).

Objectives

To develop and provide preliminary validation of the Adolescent Psoriasis Quality of Life instrument.

Methods

Qualitative interviews with adolescents with psoriasis, parents of adolescents with psoriasis, and healthcare professionals informed the development of an initial item pool for the instrument, which was subsequently refined through cognitive interviews. Finally, data from an independent sample of adolescents with psoriasis (n = 50) were used for item reduction, scale construction and initial validation, using a combination of techniques from classical test theory and Rasch modelling.

Results

Rich qualitative data concerning health‐related quality of life in adolescents with psoriasis (from 18 adolescents, 14 parents and four healthcare professionals), combined with cognitive interview testing (n = 12), resulted in a 41‐item draft version. Item reduction led to the final version, a 17‐item instrument consisting of two subscales showing good fit to their respective Rasch models: psychosocial impact (12 items) and the impact of physical symptoms and treatment (five items). All a priori stated hypotheses regarding construct validity were supported. Both subscales and the total scale showed acceptable test–retest reliabilities (intraclass correlations 0·97, 0·89 and 0·96) and internal consistencies (Cronbach's α 0·94, 0·81 and 0·95).

Conclusions

The preliminary form of the Adolescent Psoriasis Quality of Life instrument shows promising psychometric properties. It can be used in daily clinical practice and research to support a patient‐centred approach and inform treatment planning.

What's already known about this topic?

Health‐related quality of life (HRQoL) instruments should be targeted towards narrowly defined age groups, as life contexts of children, adolescents and adults may differ substantially.

Dermatology‐specific instruments have been used to measure HRQoL in adolescents with psoriasis, but it is not known whether these instruments accurately capture all relevant HRQoL aspects in adolescent psoriasis.

Age‐appropriate and psoriasis‐specific instruments may be more sensitive for HRQoL issues experienced by this unique group.

What does this study add?

The Adolescent Psoriasis Quality of Life instrument represents the first age‐appropriate and disease‐specific instrument for measuring HRQoL in adolescents (12–17 years old) with psoriasis.

It is intended for use in daily clinical practice to support dermatologists and other healthcare professionals in providing optimal care for adolescents with psoriasis.

Linked Comment: Blome. Br J Dermatol 2020; 183:9.

Safety and efficacy of topical, fixed-dose combination calcipotriene (0.005%) and betamethasone (0.064% as dipropionate) gel in adolescent patients with scalp and body psoriasis: a phase II trial

Background

Psoriasis is a disease that commonly manifests in adolescence. Up to half of adults with psoriasis develop it before the age of 20. Topical formulations containing corticosteroids and/or vitamin D3 analogs are recommended for treatment.

Objective

This phase II study aimed to evaluate the safety, including any potential effect on the hypothalamic–pituitary–adrenal axis and calcium metabolism, and efficacy of fixed‐dose combination calcipotriene (0.005%) and betamethasone (0.064% as dipropionate) (Cal/BD) gel in adolescents with psoriasis.

Methods

Patients aged 12 to <17 years, with at least mild psoriasis on the body and scalp, received topical Cal/BD gel once daily for ≤8 weeks. Safety response criteria included adverse drug reactions [ADRs; any adverse event (AE) possibly or probably related to treatment as determined by the investigator; a primary response criterion] and AEs (a secondary response criterion). Only treatment‐emergent AEs (events that occurred after the first application of Cal/BD gel or events which started before this and increased in intensity after the first application of Cal/BD gel) are presented here. Efficacy response criteria included controlled disease, by physician's global assessment of disease severity (PGA), following Cal/BD gel treatment.

Results

A total of 107 patients (median age 14 years; range 12–16) were enrolled and treated. Eight ADRs were observed in 7 (7%) patients and 38 (36%) patients experienced ≥1 AE. The most common AEs were headache [6 (6%) patients], nasopharyngitis [6 (6%) patients] and blood parathyroid hormone increased [4 (4%) patients]. One severe AE was reported (attempted suicide) but was considered unrelated to treatment. At the end of treatment, 58% of patients had controlled disease on the body and 69% on the scalp according to PGA.

Conclusion

In this uncontrolled phase II study, Cal/BD gel was well tolerated and effective for treating scalp and body psoriasis in adolescents.

Bacteriophage of the Skin Microbiome in Patients with Psoriasis and Healthy Family Controls

The bacteriophage (phage) component of the skin microbiome in patients with psoriasis has not been systematically explored. The purpose of this study is to investigate phage and bacterial components of the skin microbiome in patients with psoriasis and in healthy family controls. Lesional skin swabs of four different locations (elbow, forearm, knee, and scalp) were taken from patients with psoriasis. Healthy skin swabs of matched locations were taken from contralateral non-lesional skin and healthy family controls. Skin microbiomes were investigated using next-generation shotgun metagenomics sequencing. 81 skin microbiome samples (27 lesional skin samples and 54 healthy skin samples from contralateral non-lesional skin and family controls) obtained from 16 subjects with psoriasis and 16 matched family controls were sequenced and analyzed. Among phage species with abundant host bacteria, two significantly differential abundant phage species, Acinetobacter phage Presley and Pseudomonas phage O4 (adjusted P < 0.05), between psoriasis lesional skin and healthy skin were identified. Samples with high levels of these phage species had their host bacteria abundance suppressed (P = 0.03 and P < 0.001). Differential phage composition between lesional skin in patients with psoriasis and healthy skin from contralateral non-lesional sites and family controls, as well as the suppression of bacteria host of the respective phage, suggest possible avenues for probiotic phage therapeutics.