Skin pain and skin discomfort is associated with quality of life in patients with psoriasis

Psychological Aspects of Cutaneous Pain in Psoriasis

Introduction: Psoriasis is a chronic inflammatory disease that negatively impacts patients' quality of life (QoL) and mental health. Itch and pain are prevalent symptoms of psoriasis and contribute to the psychosocial burden of this disease. This study aimed to evaluate the impact of skin pain on the prevalence and severity of symptoms of anxiety and depression and on the QoL in psoriasis patients. Methods: The studied population comprised 106 adults with psoriasis (34% female; mean age 42.1 ± 13.0 years). Disease severity was measured with the Psoriasis Area and Severity Index (PASI). The intensity of skin pain was assessed with the NRS and the Short Form McGill Pain Questionnaire (SF-MPQ). The Generalized Anxiety Disorder-7 (GAD-7) and Patient Health Questionnaire-9 (PHQ-9) questionnaires were used to estimate the severity of depression and anxiety, respectively, as was the Hospital Anxiety and Depression Scale (HADS). Quality of life (QoL) was studied using the Dermatology Life Quality Index (DLQI). Results: Regarding anxiety assessment, females reported significantly higher scores with the HADS-A (8.42 ± 4.85 points vs. 5.14 ± 3.9 points; p < 0.001) and the GAD-7 compared to men (7.50 ± 5.58 points vs. 5.24 ± 4.79 points; p = 0.036). Similarly, the severity of depression was significantly higher in women, as measured with the PHQ-9 (7.50 ± 5.58 points vs. 5.24 ± 4.79 points, p = 0.021). Psoriasis patients with skin pain scored significantly higher in HADS Total score (p = 0.043), HADS-A (p = 0.022), PHQ-9 (p = 0.035), and DLQI (p < 0.001) than the rest of the studied group. The intensity of skin pain measured with the SF-MPQ correlated significantly with HADS Total score (p = 0.021), HADS-A (p < 0.001), HADS-D (p = 0.038), and PHQ-9 (p < 0.001). Additionally, there was a significant correlation between the intensity of cutaneous pain assessed using the VAS and the PHQ-9 (p = 0.022). Conclusions: Skin pain significantly influences the well-being of patients with psoriasis as well as the symptoms of anxiety and depression. In particular, women with psoriasis are at increased risk of developing anxiety and depression. Our findings underline the necessity for a multidisciplinary approach to the management of this dermatosis.

Defining well-being in psoriasis: A Delphi consensus among healthcare professionals and patients

Psoriasis is a chronic skin disease that negatively impacts on patient's life. A holistic approach integrating well-being assessment could improve disease management. Since a consensus definition of well-being in psoriasis is not available, we aim to achieve a multidisciplinary consensus on well-being definition and its components. A literature review and consultation with psoriasis patients facilitated the design of a two-round Delphi questionnaire targeting healthcare professionals and psoriasis patients. A total of 261 panellists (65.1% patients with psoriasis, 34.9% healthcare professionals) agreed on the dimensions and components that should integrate the concept of well-being: emotional dimension (78.9%) [stress (83.9%), mood disturbance (85.1%), body image (83.9%), stigma/shame (75.1%), self-esteem (77.4%) and coping/resilience (81.2%)], physical dimension (82.0%) [sleep quality (81.6%), pain/discomfort (80.8%), itching (83.5%), extracutaneous manifestations (82.8%), lesions in visible areas (84.3%), lesions in functional areas (85.8%), and sex life (78.2%)], social dimension (79.5%) [social relationships (80.8%), leisure/recreational activities (80.3%), support from family/friends (76.6%) and work/academic life (76.5%)], and satisfaction with disease management (78.5%) [treatment (78.2%), information received (75.6%) and medical care provided by the dermatologist (80.1%)]. This well-being definition reflects patients' needs and concerns. Therefore, addressing them in psoriasis will optimise management, contributing to better outcomes and restoring normalcy to the patient's life.

Clinical Characteristics of Cutaneous Pain in Psoriasis

Background: Psoriasis is a common inflammatory disease that is often associated with itch and pain. This study aimed to evaluate the clinical characteristics of skin pain among patients with psoriasis. Materials: A total of 106 patients diagnosed with psoriasis were included in the study (34% female; mean age 42.1 ± 13.0 years). Disease severity was assessed using the Psoriasis Area and Severity Index (PASI). Itch severity was evaluated using the numeric rating scale (NRS) and 4-Item Itch Score (4IIS). The intensity of skin pain was measured through the NRS, short-form McGill pain questionnaire (SF-MPQ), visual analog scale (VAS), and Douleur Neuropathique-4 questionnaire (DN4). Results: In the past week, 84.9% of psoriasis patients reported itch, while 50% of them reported skin pain. The average NRS for itch was 4.52 ± 2.88 points, and the 4IIS yielded a mean score of 6.79 ± 4.37 points. In terms of the intensity of cutaneous pain, the mean NRS was 2.42 ± 2.96 points; the SF-MPQ score averaged 4.84 ± 7.51 points; and the VAS score was 1.92 ± 2.65 points. Furthermore, 17% of adult psoriasis patients reported neuropathic pain. In 84.9% of the participants, skin pain was concurrent with areas affected by itch, while 18.9% of patients exhibited cutaneous pain encompassing all itchy areas. The pain NRS demonstrated significant correlations with the SF-MPQ (r = 0.531, p < 0.001), VAS (r = 0.779, p < 0.001), itch NRS (r = 0.551, p < 0.001), and 4IIS (r = 0.569, p < 0.001). No association was found between the pain NRS and PASI or disease duration. Conclusions: Skin pain of mild intensity and itch of moderate intensity are prevalent symptoms in psoriasis patients. Strong correlations between skin pain and itch can be explained by the process of neurogenic inflammation.

Effects on peripheral and central nervous system of key inflammatory intercellular signalling peptides and proteins in psoriasis

Psoriasis is a chronic systemic inflammatory cutaneous disease. Where the immune system plays an important role in its pathogenesis, with key inflammatory intercellular signalling peptides and proteins including IL-17 and IL-23. The psychoneurological system also figures prominently in development of psoriasis. There is a high prevalence of comorbidity between psoriasis and mental health disorders such as depression, anxiety and mania. Patients with psoriasis often suffer from pathological pain in the lesions, and their neurological accidents could improve the lesions in innervated areas. The immune system and the psychoneurological system interact closely in the pathogenesis of psoriasis. Patients with psoriasis exhibit abnormal levels of neuropeptides both in circulating and localized lesion, acting as immunomodulators involved in the inflammatory response. Moreover, receptors for inflammatory factors are expressed in both peripheral and central nervous systems (CNSs), suggesting that nervous system can receive and be influenced by signals from immune system. Key inflammatory intercellular signalling peptides and proteins in psoriasis, such as IL-17 and IL-23, can be involved in sensory signalling and may affect synaptic plasticity and the blood-brain barrier of CNS through the circulation. This review provides an overview of the multiple effects on the peripheral and CNS under conditions of systemic inflammation in psoriasis, providing a framework and inspiration for in-depth studies of neuroimmunomodulation in psoriasis.

Evaluation of sleep quality and pruritus severity in psoriatic patients and their impact on quality of life: a cross section correlational study

Psoriasis is a chronic inflammatory condition associated with genetic and immunological susceptibility. The objective of the study was to evaluate pruritus and sleep quality in correlation (r) to psoriasis severity and to detect their impact on quality of life. Two hundred (200) patients with psoriasis were included. Psoriasis severity was determined using the psoriasis area severity index (PASI), the quality of life (QoL) was assessed by the psoriasis disability index (PDI) questionnaire, and the sleep quality was evaluated by the Pittsburgh sleep quality index (PSQI). Finally, the severity of itching was evaluated using a 12-item pruritus severity scale (PSS). Poor sleep quality was found in 16.0% of patients in this study. Poor sleep was detected among 50.0% of cases with severe psoriasis. PASI scores correlated significantly with sleep quality, duration and sleep disturbances (p < 0.001). The global PSQI and PASI were also significantly correlated (p = 0.004). In conclusion patients complaining of psoriasis exacerbated by pruritus and sleep problems demonstrated lower quality of life in all domains. Sleep disturbances and depressive symptoms impairing quality of life should be taken into consideration when screening patients suffering from psoriasis.

Pain associated with psoriasis: a qualitative study

BACKGROUND

Pain is a major factor in the psychosocial impact of psoriasis. There is a paucity of qualitative reports of dermatologists' views on psoriasis-related pain.

OBJECTIVES

The aim of this study was to explore the views of dermatologists on the presence and importance of pain associated with psoriasis.

METHODS

This qualitative study, based on semi-structured interviews, included dermatologists from different cities working in the hospital and private sector in Croatia between May and July, 2022. We collected demographic and occupational data on participants and information about their experiences and attitudes toward psoriasis-related pain. Data were analysed by applying interpretative descriptive and thematic analysis using the 4-stage method for systematic text condensation.

RESULTS

We included 19 dermatologists, all women, aged 38 (range: 31 to 63 years). Most dermatologists acknowledged the presence of pain in patients with psoriasis. They indicated that they sometimes do not sufficiently address this pain in daily practice. Some indicated that pain was a neglected symptom in psoriasis, while for others it was not crucial. Most indicated that it is necessary to focus more on psoriasis-related pain in clinical practice, to disambiguate between skin pain and joint pain in psoriatic conditions, and to better educate family physicians about psoriasis-related pain. They emphasized the importance of considering pain during psoriatic patient assessment and management. Further research on psoriasis-related pain was suggested.

CONCLUSIONS

More emphasis is needed on psoriasis-related pain for effective management of psoriasis, informing decision-making in the context of patient-centric care and improving the quality of life in patients with psoriasis.

Tildrakizumab improves high burden skin symptoms, impaired sleep and quality of life of moderate-to-severe plaque psoriasis patients in conditions close to clinical practice

BACKGROUND

Tildrakizumab (TIL) is an interleukin (IL)-23p19 inhibitor for the treatment of moderate-to-severe plaque psoriasis with long-term efficacy and safety demonstrated in Phase III trials. Studies conducted in conditions closer to clinical practice are needed.

OBJECTIVES

The TRIBUTE study (open-label, Phase IV) assessed the efficacy and impact on health-related quality of life (HRQoL) of TIL 100 mg in adult moderate-to-severe psoriasis patients (naïve to IL-23/Th17 pathway inhibitors) in conditions similar to clinical practice.

METHODS

Key efficacy measure was Psoriasis Area Severity Index (PASI). HRQoL was evaluated using the Dermatology Life Quality Index (DLQI) and Skindex-16. Additional patient-reported outcomes included Pain-, Pruritus- and Scaling-Numerical Rating Scale (NRS), Medical Outcome Study (MOS)-Sleep, Work Productivity and Activity Impairment (WPAI), Patient Benefit Index (PBI) and Treatment Satisfaction Questionnaire for Medication (TSQM).

RESULTS

One hundred and seventy-seven patients were enrolled (six patients did not complete the study). After 24 weeks, the proportion of patients achieving PASI scores ≤ 3, PASI 75, PASI 90 and DLQI 0/1 was 88.4%, 92.5%, 74.0% and 70.4%, respectively. Skindex-16 overall score improved (mean absolute change from baseline, MACB [95%CI]: -53.3 [-58.1, -48.5]). Significant benefits (MACB [95%CI]) were found on pruritus-, pain- and scaling-NRS scores (-5.7 [-6.1, -5.2], -3.5 [-4.1, -3.0] and -5.7 [-6.2, -5.2], respectively), MOS-Sleep (-10.4 [-13.3, -7.4] Sleep problems Index II) and WPAI (-36.4 [-42.6, -30.2] activity impairment, -28.2 [-34.7, -21.7] productivity loss, -27.0 [-32.9, -21.1] presenteeism and -6.8 [-12.1, -1.5] absenteeism). 82.7% of patients reported PBI ≥ 3 and the mean (SD) global TSQM score was high (80.5 [18.5]). Only one serious treatment-emergent adverse event was reported (not-related to TIL).

CONCLUSIONS

TIL 100 mg treatment after 24 weeks in conditions close to real clinical practice showed a quick and high improvement in psoriasis signs and HRQoL. Patient reported improvements in sleep outcomes and work productivity, relevant benefits and high treatment satisfaction. The safety profile was favourable and consistent with Phase III trials.

Association of pruritus with sleep in patients with psoriasis and chronic spontaneous urticaria: A cross-sectional study

Background

Pruritus is a frequent complaint associated with various inflammatory dermatoses. Sleep is often disturbed because of pruritus but the impact of severity and diurnal pattern of pruritus has not been studied so far.

Objectives

To estimate the prevalence of nocturnal itch (NI) and its association with itch severity, sleep disturbance and quality of life (QoL) compared with non-NI in chronic plaque psoriasis (CPP) and chronic spontaneous urticaria (CSU).

Methods

We performed a cross-sectional study in patients aged ≥18 years with CPP or CSU for at least 6 weeks. A comprehensive in-house questionnaire designed for study formed the basis for categorizing patients into NI and non-NI. Validated instruments like visual analog scale, pruritus grading system, General Sleep Disturbance Scale, and Dermatology life quality index were used to assess itch severity, sleep, and QoL.

Results

A total of 255 patients (CPP: 131; CSU: 124) were included in this study. Prevalence of NI was 43.5% (95% confidence interval: 34.9%-52.4%) in CPP and 29% (95% confidence interval: 21.2%-37.9%) in CSU. NI was strongly associated with higher pruritus grading system scores in CSU and CPP (regression coefficient = 1.5, P =0.004 and regression coefficient = 1.3, P =0.004, respectively), with impaired sleep (OR = 2.97, P = 0.025) in CPP and with itch-affected sleep in CSU. Itch severity was associated with impaired sleep; however, the association was modified by the presence of NI in CSU patients.

Conclusion

Nocturnal itch is prevalent in chronic dermatoses and significant for sleep deficit and impaired QoL. Early screening and management of sleep disturbance among patients presenting with nocturnal itch should be routinely undertaken.

Treatment with brodalumab is not associated with improved sleep problems in real-life patients with plaque psoriasis: Results of the ProLOGUE study

Psoriasis impacts various aspects of patients' health-related quality of life and is associated with sleep problems. However, research discussing the associations between interleukin-17 blockage therapies and sleep problems in patients with psoriasis is insufficient. We aimed to assess the effectiveness of brodalumab in alleviating sleep problems in real-life patients with plaque psoriasis. This analysis was part of the single-arm, open-label, multicenter, prospective, cohort study, ProLOGUE (study period October 2017-March 2020), which involved Japanese patients with plaque psoriasis. Assessments included correlation of Medical Outcomes Study Sleep Scale-Revised (MOS Sleep-R) scores (Sleep Problems Index-II [SPI-II] and MOS Sleep-R subscale scores) with multiple patient-reported outcome scores and the Psoriasis Area and Severity Index (PASI) at baseline. Additionally, change from baseline in MOS Sleep-R scores was assessed at weeks 12 and 48 of brodalumab treatment. Seventy-three patients were enrolled (male 82.2%, median age 54.0 years). At baseline, the SPI-II score correlated with the Patient Health Questionnaire-8 score (Spearman correlation coefficient [ρ] = -0.474) and weakly correlated with the Itch Numeric Rating Scale (NRS; ρ = -0.366), Skin Pain NRS (ρ = -0.275), and all Treatment Satisfaction Questionnaire for Medication-9 domain scores (ρ = 0.270, ρ = 0.303, and ρ = 0.322 for effectiveness, convenience, and global satisfaction, respectively) but did not correlate with the PASI score. The SPI-II score and MOS Sleep-R subscale scores, except the Snoring score (p = 0.0319), did not significantly change from baseline to week 12 of brodalumab treatment. In conclusion, treatment with brodalumab did not improve overall sleep problems in real-life patients with plaque psoriasis, suggesting that sleep problems require attention in daily clinical practice (Japan Registry of Clinical Trials identifier, jRCTs031180037).

Real-world effectiveness and safety of tildrakizumab in long-term treatment of plaque psoriasis: Results from the non-interventional, prospective, multicentre study TILOT

BACKGROUND

Plaque psoriasis is a chronic inflammatory disorder affecting the skin and impacting quality of life. Tildrakizumab (TIL) is an IL-23 inhibitor licensed for moderate-to-severe plaque psoriasis. Regulatory approval of medicinal products is based on safety and efficacy data from randomized controlled trials (RCTs) which impose stringent selection criteria. Long-term non-interventional studies (NIS) are needed to establish effectiveness and safety in daily practice bridging the gap between RCTs and the real-world setting.

OBJECTIVES

This analysis of the NIS TILOT seeks to evaluate effectiveness and safety of TIL in patients with moderate-to-severe plaque psoriasis in a real-world setting. Secondary objectives include the assessment of the Dermatology Life Quality Index (DLQI), treatment satisfaction and course of scalp and nail disease using Physician Global Assessment (PGA).

METHODS

Interim analysis at 52 weeks (W) of the ongoing non-interventional, prospective, long-term multicentre study TILOT.

RESULTS

The effectiveness analysis included 412 patients. The mean [standard deviation, SD] Psoriasis Area and Severity Index (PASI) score was 16.0 [9.1] at baseline improving by 82.4% (95% confidence interval [CI], 78.9-86.0) to 2.1 [2.9] at W52. The proportion of patients achieving PASI scores of <3 and <5 increased over time peaking at 74.6% (95% CI, 69.3-79.4) and 88.4% (95% CI, 84.3-91.8) at W52. Scalp-PGA and nail-PGA improved by 79.8% (95% CI, 75.6-84.0) and 72.7% (95% CI, 63.9-81.6), respectively. DLQI of 0/1 was achieved by 48.2% (95% CI, 42.3-54.2). Nine out of 10 physicians and patients expressed a high level of treatment satisfaction. No new safety signals were observed.

CONCLUSIONS

This prospective cohort study demonstrates a high degree of effectiveness and a reassuring safety profile of TIL in a real-world setting over 52 weeks. Patients with scalp and nail involvement or pruritus showed marked improvements.

Effectiveness of brodalumab in improving itching and skin pain in Japanese patients with psoriasis: The ProLOGUE study

Itching and skin pain are bothersome symptoms of psoriasis, but evidence is limited regarding the treatment effectiveness on these symptoms in daily clinical settings. We assessed the changes in the levels of itching and skin pain after brodalumab treatment in Japanese patients with psoriasis using patient-reported outcomes (PROs). Patients with psoriasis who have inadequate response to existing treatments were enrolled in the single-arm, open-label, multicenter, prospective ProLOGUE study and received brodalumab 210 mg subcutaneously in daily clinical practice. Psoriasis Area and Severity Index (PASI) and PRO assessments were performed at baseline and weeks 12 and 48. Seventy-three patients (men, 82.2%; median age, 54.0 years) were enrolled. The Itch Numeric Rating Scale (NRS; p < 0.0001 at weeks 12 and 48) and Skin Pain NRS (week 12, p = 0.0004; week 48, p < 0.0001) scores significantly decreased from baseline. The Itch NRS score was significantly higher in patients with a Dermatology Life Quality Index (DLQI) score of ≥2 (vs. 0/1; p < 0.0001 at weeks 12 and 48) and in patients with a Treatment Satisfaction Questionnaire for Medication-9 (TSQM-9) global satisfaction domain score of ≤70% (vs. >70%; week 12, p = 0.0120; week 48, p = 0.0348). The Itch NRS score cutoff value for achieving a PASI score of ≤2, DLQI score of 0/1, and TSQM-9 global satisfaction domain score of >70% was 1 at week 12 and 0 at week 48. Brodalumab treatment was associated with improvement in itching and skin pain in Japanese patients with psoriasis. An Itch NRS score of 0 can be a long-term treatment goal for psoriasis (Japan Registry of Clinical Trials identifier: jRCTs031180037).

Sleep Disorders and Psoriasis: An Update

Psoriasis alters patients’ quality of life. Among the disorders associated with psoriasis, sleep disorders are common, although they are not directly assessed by most quality-of-life scores. Thus, the specific evaluation of sleep disorders using dedicated scores is necessary, especially because such disorders alter patients;’ physical and psychological health. The relationship between psoriasis and sleep disorders has been shown in numerous studies, but has not yet been fully elucidated. The aim of this study was to update knowledge of sleep disorders in patients with psoriasis, through a review of the scientific literature since 1980. This work covers several topics of interest, such as sleep assessment methods, the prevalence of sleep disorders in patients with psoriasis, factors predictive of sleep disorders in patients with psoriasis, the impact of sleep disorders on comorbidities and quality of life, pathogenic mechanisms, obstructive sleep apnoea and restless leg syndromes, and the impact of biotherapy treatments on sleep disorders in patients with psoriasis.

Increased prevalence of sleep disturbance in psoriatic arthritis is associated with inflammatory and non-inflammatory measures

OBJECTIVES

To examine the prevalence of sleep disturbances, quantified by the Pittsburgh Sleep Quality Index (PSQI), in patients with psoriatic arthritis (PsA), psoriasis (PsO) and healthy controls (HCs), explore associations between PSQI and clinical and patient-reported outcomes, and evaluate the effect of treatment on PSQI.

METHOD

Patients were included from the Parker Institute's PsA patient cohort to evaluate the prevalence of sleep disturbances. Univariate and multivariate regression analyses were used to explore associations between sleep disturbance and outcome measures. Treatment effect in PsA patients was assessed with a mixed-effect model for repeated measures.

RESULTS

In total, 109 PsA patients, 20 PsO patients, and 20 HCs were included. Sleep disturbances were reported by 66.1% of PsA patients, 45.0% of PsO patients, and 15.0% of HCs. Univariate regression analyses revealed statistically significant associations (p < 0.001) between PSQI and Disease Activity Score (DAS28CRP), tender points, visual analogue scale (VAS) patient global and pain, Psoriatic Arthritis Impact of Disease fatigue, Health Assessment Questionnaire (HAQ), and painDETECT score. Multivariate regression analysis demonstrated VAS patient global, VAS pain, and tender points as being independently associated with PSQI. The mixed-effect model revealed no effect of treatment.

CONCLUSION

More PsA patients than PsO patients and HCs reported sleep disturbances. Sleep disturbances were associated with inflammatory and non-inflammatory measures possibly explaining the limited effect of treatment. This demonstrates the need for interdisciplinary approaches to improve the management of sleep disturbance in PsA.Trial registration: ClinicalTrials.gov (NCT02572700).

Exploring cannabis use and perspectives among psoriatic disease patients

OBJECTIVE

To assess the correlation between cannabis use and psoriatic disease severity, health-related quality of life, pain, psychosocial outcomes, and cytokine levels in psoriasis (PsC) and psoriatic arthritis (PsA) patients.

METHODS

PsC and PsA patients enrolled in the International Psoriasis and Arthritis Research Team (IPART) program were surveyed on cannabis use and were asked to provide a serum and urine sample. Demographic and clinical variables were compared between users and non-users using Student's t-test or Mann-Whitney U test for continuous variables, and chi-square or Fisher's exact test for categorical variables.

RESULTS

Of 151 respondents, 30% reported current cannabis use within the last year. Compared to non-users, cannabis users were younger and had a shorter PsA duration and poorer mental health as measured by the SF-36. Other measures of health-related quality of life and pain were comparable between the groups. Respondents' primary perceived benefits of cannabis use were aid in sleep and arthritis pain relief, but there was no difference in pain between users and non-users. No THC was detected in the urine of non-users while users had a mean level of 19.6 ng/ml. Serum IL-23 levels were statistically significantly higher in non-users than in users.

CONCLUSION

A third of the patients used cannabis within the past year, and 54.3% of users reported the use of cannabis for arthritis pain relief. However, there was no difference in pain scores. Comprehensive education for providers on the current body of evidence and further studies on cannabis use and outcomes in psoriatic disease are needed. Key Points • A third of patients with psoriatic arthritis have used cannabis in the past year. • Most used it for better sleep and control of pain. • There was no difference in pain scores between users and non-users. • IL-23 levels were significantly higher in non-users.

Change in psoriatic arthritis outcome measures impacts SF-36 physical and mental component scores differently: an observational cohort study

Objective

The objective was to investigate interplay and physical and mental component scores between change (Δ) in health-related quality of life (HRQoL) quantified by the physical component score (PCS) and mental component score (MCS) retrieved from short-form health survey (SF-36), change in disease activity (ΔDAS28CRP) and manifestations of PsA.

Methods

PsA patients initiating new medical therapy were enrolled. Independent disease measures evaluating disease activity, enthesitis, psoriasis, pain and fatigue were collected at treatment initiation and after 4 months. Interplay between independent disease measures and dependent outcome measures, ΔPCS and ΔMCS, was described with univariate regression analyses. Multivariate regression analyses were applied to assess the impact of independent variables, such as individual disease outcome measures vs ΔDAS28CRP on ΔPCS and ΔMCS.

Results

One hundred and eight PsA patients were included. In the univariate regression analyses, improvement in fatigue, pain and disability were associated with improvement in ΔPCS (β; -2.08, -0.18 and -13.00, respectively; all P < 0.001) and ΔMCS (β; -1.59, -0.12 and -6.07, respectively; P < 0.001, P < 0.001 and P = 0.003, respectively). When patient-reported outcomes were included in the final multivariate models, improvements in ΔPCS and ΔMCS were associated with improvements in pain, fatigue and disability (P < 0.001). Improvement in enthesitis impacted ΔPCS positively (β -0.31, P < 0.001). No association was found between change in skin psoriasis, ΔPCS and ΔMCS (β 0.15, P = 0.056 and β 0.05, P = 0.561, respectively).

Conclusion

In this PsA patient cohort, diminishing pain, disability and fatigue improved PCS and MCS significantly. Changes in enthesitis and psoriasis did not grossly impact HRQoL compared with DAS28CRP. Individual PsA manifestations influence HRQoL differently, which is important clinically when targeting treatment.

Trial registration

ClinicalTrials.gov, http://clinicaltrials.gov, NCT02572700.

Nociceptive Sensory Fibers Drive Interleukin-23 Production in a Murine Model of Psoriasis via Calcitonin Gene-Related Peptide

Neuroimmunity is involved in the pathogenesis of psoriasis, but the mechanism underlying the interaction between the nervous system and the interleukin (IL)-23/IL-17 immune axis is yet unclear. This study reveals the essential role of the sensory neuron-derived calcitonin gene-related peptide (CGRP) in imiquimod (IMQ)-induced expression of IL-23. First, we show that the increased nociceptive behavior was consistent with the development of psoriasiform dermatitis, which requires intact sensory innervation. Systemic ultrapotent Transient receptor potential vanilloid 1 (TRPV1) agonist (resiniferatoxin, RTX) treatment-induced sensory denervation resulted in a significant decrease in IL-23 expression in this model, while the recombinant IL-23 treatment induced IL-17A expression was intact after RTX treatment. In addition, IMQ exposure induced a transient increase in CGRP expression in the dorsal root ganglion. The neuron-derived CGRP expression was completely abolished by sensory denervation, thereby downregulating IL-23 expression, which could be reversed through the introduction of CGRP into the denervated dorsal skin. Our results suggest that nociceptive sensory neurons may drive the production of IL-23, resulting in IL-17A production from γδ T cells via the neuropeptide CGRP in the pathology of psoriasis.

[The effect of treatment expectations on pruritus and skin pain]

Hintergrund

Patientenerwartungen in Bezug auf den Nutzen einer medizinischen Behandlung stellen eine wichtige Determinante für die Placeboantwort dar. Sie können Entwicklung und Verlauf von Erkrankungen sowie Wirksamkeit und Verträglichkeit von Therapien maßgeblich beeinflussen. Die Mechanismen, die diese Placebo- und Noceboeffekte vermitteln, wurden bislang am besten auf dem Gebiet der Placeboanalgesie beschrieben. Aber auch in der Dermatologie findet sich eine zunehmende Evidenz dafür, dass verschiedene Symptome wie Schmerzen an der Haut und Pruritus (Jucken) sowie verschiedene dermatologische Erkrankungen durch die Behandlungserwartungen von Patienten moduliert werden können.

Ziel der Arbeit

Das Ziel dieser Arbeit ist die Darstellung der aktuellen Datenlage in Bezug auf den Einfluss von Erwartungseffekten auf dermatologische Symptome wie Pruritus und Hautschmerzen sowie auf verschiedene dermatologische Erkrankungen. Schließlich soll die Bedeutung dieses Themas für Ärzte, die Patienten mit Hautsymptomen behandeln, vermittelt werden.

Material und Methoden

Es handelt sich um eine narrative Übersichtsarbeit.

Ergebnisse und Diskussion

Eine zunehmende Anzahl von Studien an gesunden Probanden und dermatologischen Patienten zeigt, dass Hautsymptome wie Pruritus und Schmerzen durch die Induktion positiver Erwartungen verringert und durch die Induktion negativer Erwartungen verstärkt werden können. Vorherige Behandlungserfahrungen der Patienten sowie die Qualität und Quantität der Arzt-Patienten-Kommunikation spielen für die Induktion der Behandlungserwartung eine zentrale Rolle.

Schlussfolgerung

Techniken, die darauf abzielen, positive Erwartungseffekte von Patienten mit Hautsymptomen zu maximieren und negative zu minimieren, sollten in die klinische Routine implementiert werden.

Impact of an eHealth Smartphone App on the Mental Health of Patients With Psoriasis: Prospective Randomized Controlled Intervention Study

Background

Psoriasis has a negative impact on patients’ physical and mental health and can lead to anxiety and depression. Disease management strategies, including educational programs and eHealth devices, have been shown to improve health care for several chronic diseases. However, such disease management strategies are lacking in the routine care of patients with psoriasis.

Objective

This study aims to study the impact of a novel intervention that combines an educational program with a disease management smartphone app on the mental health of patients with psoriasis.

Methods

Patients with psoriasis in the intervention group received an educational program; attended visits on weeks 0, 12, 24, 36, and 60; and had access to the study app. Patients in the control group only attended the visits. The primary endpoint was a significant reduction of scores on the Hospital Anxiety and Depression Scale (HADS). Secondary end points were reductions in Dermatology Life Quality Index score, Psoriasis Area and Severity Index score, pruritus, and pain, as well as improvements in mood and daily activities. In addition, modulating effects of sex, age, disease duration, and app use frequency were evaluated.

Results

A total of 107 patients were included in the study and randomized into the control group (53/107, 49.5%) or intervention group (54/107, 50.5%). Approximately 71.9% (77/107) of the patients completed the study. A significant reduction in HADS-Depression (HADS-D) in the intervention group was found at weeks 12 (P=.04) and 24 (P=.005) but not at weeks 36 (P=.12) and 60 (P=.32). Patient stratification according to app use frequency showed a significant improvement in HADS-D score at weeks 36 (P=.004) and 60 (P=.04) and in HADS-Anxiety (HADS-A) score at weeks 36 (P=.04) and 60 (P=.05) in the group using the app less than once every 5 weeks. However, in patients using the app more than once every 5 weeks, no significant reduction in HADS-D (P=.84) or HADS-A (P=.20) score was observed over the 60-week study period compared with that observed in patients in the control group. All findings were independent of sex, age, and disease duration.

Conclusions

These findings support the use of a disease management smartphone app as a valid tool to achieve long-term improvement in the mental health of patients with psoriasis if it is not used too frequently. Further studies are needed to analyze the newly observed influence of app use frequency.

Trial Registration

Deutsches Register Klinischer Studien DRKS00020755; https://tinyurl.com/nyzjyvvk

Nocturnal pruritus and sleep disturbance associated with dermatologic disorders in adult patients

Nocturnal pruritus (NP) is a relatively common reason for dermatologic consultation. Its pathophysiology is partially understood. Skin conditions such as atopic dermatitis, psoriasis, urticaria, and prurigo nodularis are well-described causes of NP. The most distressing sequela of NP is sleep deficit, which can lead to physical and mental disturbances (e.g., daytime somnolence and fatigue) and negative emotional states that profoundly affect quality of life. However, this aspect of NP is often overlooked by dermatologists. It is essential to assess sleep quality in such patients and adopt appropriate measures to arrest the problem at an early stage. We conducted an evidence-based literature review to highlight the pathogenetic mechanisms of NP, identify dermatologic etiologies, and explore methods that have been used to assess the quality of sleep. Furthermore, we performed a systematic review of studies on sleep disturbance relevant to NP in patients with dermatologic conditions. Finally, we discuss the evidence on treatment options for NP and indicate therapies that may target both NP and sleep disturbance.

Outcome domains and measures for pain in psoriasis used in registered trials: analysis of studies on ClinicalTrials.gov

Aim: Psoriasis includes unpleasant symptoms such as pain. This study aimed to investigate whether clinical trials have domains related to pain in their study designs. Materials and methods: We analyzed all clinical trials about interventions for psoriasis treatment registered on ClinicalTrials.gov and the frequency of pain-related outcomes. Results: Our analysis included 1033 registered clinical trials. They had 1329 primary outcomes and 5457 secondary outcomes. The pain was used in six (0.6%) protocols as a primary outcome and 68 (6.5%) protocols as a secondary outcome. Conclusion: Pain as an outcome was used in few registered clinical trial protocols for the treatment of psoriatic conditions. Future studies should investigate why the trialists do not include pain among primary or secondary outcomes.

Sleep disturbance in adult dermatologic patients: A cross-sectional study on prevalence, burden, and associated factors

BACKGROUND

Sleep disturbance remains insufficiently characterized in many dermatoses.

OBJECTIVE

To investigate the prevalence, burden, and factors associated with sleep disturbance in dermatologic patients.

METHODS

We recruited 800 patients and recorded pruritus characteristics and sociodemographic and clinical parameters. Validated questionnaires were used to assess sleep disturbance, psychological distress, health-related quality of life, and work productivity.

RESULTS

Two thirds of patients met criteria of poor sleep, which was associated with psychological distress, diminished health-related quality of life, and lost work productivity. Patients with average and maximum pruritus on the visual analog scale exceeding 5 and 6.5 points, respectively, were at high risk of suffering pruritus-related sleep disturbance. Overall pruritus intensity and its nocturnal exacerbation contributed independently to sleep disturbance. Psychological distress was of even higher impact on sleep than pruritus and almost a third of the relationship between pruritus intensity and sleep was mediated by psychological distress.

CONCLUSION

Sleep disturbance is prevalent in dermatologic patients and constitutes a considerable burden.

CLINICAL IMPLICATION

Dermatologic patients with intense pruritus and psychological distress should be examined for sleep disorders. Adequate antipruritic therapy and complementary psychotherapy in affected patients may help them regain restorative sleep.

Clinical and epidemiologic features of psoriasis patients in an Egyptian medical center

Background

Identification of epidemiologic and phenotypic variations of psoriasis among different ethnic groups can further our understanding of this perplexing disease, aiming at better management of patients worldwide.

Objective

To provide a descriptive analysis of psoriasis patients registered at Kasr Al-Ainy Psoriasis Unit Disease Registry.

Methods

This retrospective single-center registry study included patient records between November 2015 and November 2018 (2534 patients). Sociodemographic and phenotypic data were analyzed.

Results

The mean age of the registered patients was 39.3 years and 56.3% were men. Stress was the main precipitating factor (48.3%), whereas the most common symptom reported was itching (82.4%). The median body mass index was 27.5, and the median percentage of body surface area involved was 10.0. The mean Psoriasis Area Severity Index score was 8.7, and the mean Psoriasis Disability Index score was 13.0. Both parameters correlated positively, and both showed significantly higher means in smokers.

Limitations

Despite that the study was performed at a highly specialized tertiary care center with a high flow of patients, this was still a single-center registry.

Conclusions

This work shows that the characteristics of Egyptian patients with psoriasis are comparable to those of other studied ethnic groups, with minor differences.

Pain associated with psoriasis: systematic scoping review protocol

INTRODUCTION

Psoriasis is a common chronic skin inflammatory disease. Its presentation, apart from affected skin areas, involves other unpleasant symptoms, such as pain. Pain deteriorates the patient's quality of life, impairing their daily behaviour and functioning. Therefore, the alleviation of pain in patients with psoriasis should be one of the most desired outcomes of successful treatment. The aim of this study is to summarise available evidence about pain in patients with psoriasis using systematic scoping review methodology in order to map the relevant literature.

METHODS AND ANALYSES

Our scoping systematic review will provide evidence synthesis of the literature, both quantitative and qualitative, about the pain associated with psoriasis, including pain associated with psoriatic arthritis. Any types of studies will be eligible for inclusion, and we will not have any time, language or publication status restrictions. We will search MEDLINE, Embase and PsycINFO via OVID, as well as Cochrane Central Register of Clinical Trials, Cochrane Database of Systematic Reviews via Cochrane Library, CINAHL via EBSCO, OpenGrey and ProQuest Dissertations and Theses Global. All databases will be searched from the date of their inception. Retrieved bibliographic records and potentially relevant full texts will be screened by two authors independently. Two researchers will extract data independently. Any discrepancies will be resolved via discussion or consultation of the third author, if necessary. To appraise studies, we will use a Mixed Methods Appraisal Tool, AMSTAR 2, Cochrane risk of bias tool and ROBINS. Our findings will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews.

ETHICS AND DISSEMINATION

The proposed study will not be conducted with human participants. We will only use published data and therefore ethics approval is not required. Our findings will be disseminated via peer-reviewed manuscript and conference reports.

General Sleep Disturbance Scale (GSDS-IT) in people with spinal cord injury: a psychometric study

STUDY DESIGN

Psychometric study.

OBJECTIVE

This study sought to analyze the psychometric properties of the Italian version of the General Sleep Disturbance Scale (GSDS-IT) in a population of individuals with spinal cord injury (SCI).

SETTING

Italy.

METHODS

Its reliability was assessed using the Cronbach's alpha and intraclass correlation coefficient (ICC), while its concurrent validity was assessed using the Pearson's correlation coefficient in relation to the Pittsburgh Sleep Quality Index (PSQI). The obtained scores were compared with the cut-off score for the GSDS-IT among a healthy Italian population (38.5).

RESULTS

The GSDS-IT was administered to 57 participants with SCI who were recruited from all over Italy. The GSDS-IT was found to have good internal consistency (Cronbach's α of 0.76) and good test-retest reliability (ICC of 0.7), and it showed positive and significant values for all the PSQI domains. Based on the cut-off score of 38.5, 56% of participants tested positive for sleep disturbances upon admission (t0), while among the randomized participants submitted for the test-retest after 24 h (t1), 75% tested positive for sleep disturbances.

CONCLUSION

The GSDS-IT is a valid, reliable, and time-efficient tool for measuring sleep disturbances over the past week in a population with SCI.

Prevalence and Severity of Dermatological Condition-Associated Skin Pain in the Chinese

BACKGROUND/AIM

Although the characteristics of cutaneous sensory symptoms in the general population have been documented, dermatological condition-associated skin pain has not been characterized yet. In the present study, we aimed to characterize dermatological condition-associated skin pain in the Chinese.

SUBJECTS AND METHODS

A questionnaire was given to outpatients to identify self-proclaimed skin pain at our dermatology clinic. The severity of skin pain was assessed using pain scale 0-10. Prevalence and pain severity were compared between males and females.

RESULTS

A total of 2144 patients, including 1254 females and 890 males aged 13-94 years, were included in this study. The overall prevalence of skin pain was 9.93% in this cohort. The prevalence of skin pain varied greatly with dermatological conditions (p<0.0001). Moreover, a higher prevalence of skin pain was observed in males than in females (p<0.05). Among the dermatological conditions reported, higher skin pain scales were found in subjects with either glucocorticoid-induced dermatitis (4.20 ± 0.73) or herpes zoster (4.00 ± 0.29). While the overall pain scales were comparable between males and females (2.38 ± 0.13 versus 2.68 ± 0.13), pain scales in patients with eczematous dermatitis were higher in females than in males (p<0.05). Furthermore, pain scales correlated positively with age. However, pain scales did not differ between subjects with versus without a family history of cutaneous sensory symptoms. These results demonstrate that the prevalence and severity of dermatological condition-associated skin pain vary with dermatological conditions and gender in the Chinese.

CONCLUSION

Patients with some dermatological conditions may experience skin pain. Although the pain is moderate, it can negatively impact the quality of patients' lives. Alleviation of skin pain should be considered when treating patients with certain dermatological conditions.

The complex experience of psoriasis related skin pain: a qualitative study

Background and aims

Psoriasis is a common chronic skin condition, causing skin lesions with thickened and scaling skin, as well as erythema and inflammation that may involve painful sores, cracks, and pustules. Previously psoriasis was regarded as a painless skin condition. However, over the past decade studies show that skin pain is a frequently reported and bothersome symptom in patients with psoriasis. There is however a lack of rich narratives describing the experience of skin pain in these patients. The aims of this qualitative study were therefore to explore in depth how patients experience psoriasis-related skin pain, and how they deal with it.

Methods

Thirteen patients with psoriasis were recruited from a dermatology ward and outpatient clinic. One of the investigators (TML) performed individual, semi-structured interviews at an undisturbed room in the hospital. Interviews were thematically analyzed using the method of Systematic Text Condensation as described by Malterud (2012).

Results

Three main themes were identified from the interviews. First, the skin pain experience was complex. Patients used a variety of adjectives and metaphors to describe their pain, and their skin was sensitive to stimuli of every-day activities. Itch was a common cosymptom, and could both mask pain but also cause severe pain due to excessive scratching and damage to the skin. Second, skin pain had a negative impact on patients’ life. Skin pain reduced their physical activity level, impaired their sleep, and made them irritable, depressed, unconcentrated on tasks, as well as withdrawn from other people and social activities. Third, patients dealt with their skin pain in various ways. Although some took action to relieve the pain and distract themselves from pain, most of the patients applied maladaptive and passive coping strategies such as put up with it, avoid painful activities, become fearful or trivialize their pain.

Conclusions

The experience of psoriasis related skin pain is complex. The pain has a major negative impact on patients’ life in terms of physical, emotional, cognitive, and social functions. Patients use a variety of adaptive but most frequently maladaptive coping strategies in order to deal with their skin pain.

Implications

This study provides new and in-depth knowledge on psoriasis related skin pain. This information is valuable for further work on pain assessment tools and pain management recommendations customized for skin pain experienced by patients with psoriasis.

Highlights of the updated Dutch evidence- and consensus-based guideline on psoriasis 2017

Linked Comment: https://doi.org/10.1111/bjd.17390.

Analyzing the value of an educational program for psoriasis patients: a prospective controlled pilot study

Background

Psoriasis is a chronic inflammatory skin disease associated with a reduced life-quality. Severe disease forms put the patients at risk for life-treating cardiovascular events, metabolic, and other immune-mediated disorders. Psoriasis patients are often not sufficiently informed about their condition leading to suboptimal treatment adherence and, consequently, worse patient outcome. We investigated the value of an educational program on knowledge and self-expertise about the disease in psoriasis patients in general and dependent on age and disease duration.

Methods

Regular visit psoriasis-patients were asked to participate and choose to receive an additional educational program or not. Participating patients (n = 53) filled out two questionnaires: one at study inclusion and one at the next regular visit or after the absolved educational program. Surveys included disease knowledge assessment and numeric rating scales (0–10) for self-expertise about the disease, therapy adherence, and therapy satisfaction. The Dermatology Life Quality Index (DLQI) was used to investigate the quality of life.

All continuous parameters were examined for statistically significant differences by paired t-test or unpaired t-test. Continuous parameters without Gaussian distribution were analyzed with the Wilcoxon matched pairs test or the Mann-Whitney test. For all categorical parameters, Fisher’s exact test was used.

Results

Patients who chose to be educated (n = 24) showed a significant increase in knowledge, self-expertise about the disease and amelioration of general health. No positive short-term effects were seen on the quality of life and therapy adherence. Analyzing the effect of age and disease duration, the educational program led to significant improvement of the emotional well-being in older patients (≥50 years) and with a longer disease duration as well as significant amelioration of the self-expertise about psoriasis in younger patients (< 50 years).

Conclusions

Patients who chose to participate in an educational program show a higher gain in knowledge and self-expertise about the psoriatic disease. Educational program thus might have a positive effect on the long-term management of psoriasis. Further long-term studies are needed to provide evidence for the influence educational programs have on outcome, quality of life, and treatment adherence of psoriatic patients.

Trial registration

Deutsches Register Klinischer Studien DRKS00017318 (09.10.2019), retrospectively registered.

Diagnostic and therapeutic guidelines for plaque psoriasis - Brazilian Society of Dermatology

Psoriasis is a chronic inflammatory disease that affects 1.3% of the Brazilian population. The most common clinical manifestations are erythematous, scaling lesions that affect both genders and can occur on any anatomical site, preferentially involving the knees, elbows, scalp and genitals. Besides the impact on the quality of life, the systemic nature of the disease makes psoriasis an independent risk factor for cardiovascular disease, especially in young patients with severe disease. By an initiative of the Brazilian Society of Dermatology, dermatologists with renowned clinical experience in the management of psoriasis were invited to form a work group that, in a partnership with the Brazilian Medical Association, dedicated themselves to create the Plaque Psoriasis Diagnostic and Treatment Guidelines. The relevant issues for the diagnosis (evaluation of severity and comorbidities) and treatment of plaque psoriasis were defined. The issues generated a search strategy in the Medline-PubMed database up to July 2018. Subsequently, the answers to the questions of the recommendations were devised, and each reference selected presented the respective level of recommendation and strength of scientific evidence. The final recommendations for making up the final text were worded by the coordinators.

Treating to Target(s) With Interleukin-17 Inhibitors

Background:

The treat-to-target (T2T) strategy has become established in several medical specialties as a key guidance to optimal therapeutic decision making. T2T may be effective in the assessment of the biologic class of agents called interleukin (IL)-17 inhibitors, which are emerging as a safe and effective treatment option for autoimmune inflammatory conditions such as plaque psoriasis, psoriatic arthritis (PsA), and ankylosing spondylitis (AS).

Objective:

The objective of this article is to use a T2T approach for the evaluation of the effectiveness and safety of IL-17 inhibitors in the management of patients with plaque psoriasis, PsA, and AS.

Methods:

Following a comprehensive literature search, a full-day meeting was convened to discuss and identify the T2T targets for psoriasis, PsA, and AS. Clinical trial evidence was presented for the approved IL-17 inhibitors—secukinumab, ixekizumab, and brodalumab—to assess whether these data meet T2T safety and efficacy targets.

Results:

All 3 approved agents were significantly superior to placebo and active controls in the achievement of T2T targets for psoriasis. Secukinumab and ixekizumab were likewise associated with significantly better outcomes than controls in the PsA targets, and secukinumab resulted in significant AS target improvements vs placebo. The IL-17 inhibitors were also associated with low rates of serious adverse events and exacerbations of common comorbid conditions.

Conclusion:

Phase III trial results support the T2T benefit and safety of IL-17 inhibitors according to their specific indications for the management of patients with plaque psoriasis, PsA, and AS.

Intensive care survivor-reported symptoms: a longitudinal study of survivors' symptoms

BACKGROUND

There is growing interest in potential long-term outcomes following intensive care, but few researchers have studied the prevalence of multiple symptoms or the association between pain and other symptoms.

AIMS

To investigate the prevalence of anxiety, depression, fatigue, sleep disturbance and post-traumatic stress symptoms (PTSS) among intensive care survivors 3 months and 1 year after being discharged from an intensive care unit (ICU) and to determine whether pain is associated with higher prevalence of these symptoms 3 months and 1 year after ICU stay.

STUDY DESIGN

Exploratory, longitudinal cohort of intensive care survivors from two mixed ICUs in a tertiary referral hospital in Norway.

METHODS

Intensive care survivors completed surveys at 3 months (n = 118) and 1 year (n = 89) after ICU discharge. Clinical Trials: NCT02279212.

RESULTS

Prevalence rates of intensive care survivors' symptoms were pain 58 (49·2%), anxiety/depression 24/118 (20·8%), fatigue 18/118(15·3%), PTSS 15 (12·8%) and sleep disturbance 58/118 (49·2%) at 3 months after ICU discharge (n = 118). Prevalence rates at 1 year (n = 89) changed only slightly to pain 34 (38·2%), anxiety/depression 17 (20·0%), fatigue 12 (13·8%), PTSS 13 (15·1%) and sleep disturbance 40/89 (46·5%). Associations were strong between pain and presence of sleep disturbance, anxiety/depression, PTSS and fatigue.

CONCLUSIONS

Intensive care survivors have multiple symptoms and the prevalence rates of these symptoms remained almost unchanged from 3 months to 1 year after ICU discharge. The presence of pain was associated with high odds for the presence of sleep disturbance, anxiety/depression, PTSS and fatigue, compared to a no-pain group. ICU survivors may benefit from targeted interventions designed to alleviate the symptom burden.

RELEVANCE TO CLINICAL PRACTICE

Knowledge about ICU survivor's prevalence and risk for having multiple symptoms may help health care professionals to give better care, if needed, to the ICU survivors.

The Impact of Skin Problems on the Quality of Life in Patients Treated with Anticancer Agents: A Cross-Sectional Study

PURPOSE

Patients treated with anticancer agents often experience a variety of treatment-related skin problems, which can impair their quality of life.

Materials and Methods

In this cross-sectional study, Dermatology Life Quality Index (DLQI) and clinical information were evaluated in patients under active anticancer treatment using a questionnaire survey and their medical records review.

RESULTS

Of 375 evaluated subjects with anticancer therapy, 136 (36.27%) and 114 (30.40%) were treated for breast cancer and colorectal cancer, respectively. We found that women, breast cancer, targeted agent use, and longer duration of anticancer therapy were associated with higher dermatology-specific quality of life distraction. In addition, itching, dry skin, easy bruising, pigmentation, papulopustules on face, periungual inflammation, nail changes, and palmoplantar lesions were associated with significantly higher DLQI scores. Periungual inflammation and palmoplantar lesions scored the highest DLQI.

CONCLUSION

We believe our findings can be helpful to clinicians in counseling and managing the patients undergoing anticancer therapy.

Improvement of health-related quality of life and adherence to treatment with calcipotriol-betamethasone dipropionate gel in patients with psoriasis vulgaris

BACKGROUND

Psoriasis is a common, chronic, recurrent, immune-mediated disorder of the skin and joints. It can have a significant negative impact on the physical, emotional and psychosocial wellbeing of affected patients.

OBJECTIVES

To measure improvement in health-related QoL (HRQoL) in Greek patients with psoriasis vulgaris after a month of treatment with calcipotriol-betamethasone dipropionate gel; and evaluate adherence to treatment parameters.

METHODS

The study included 394 psoriasis vulgaris patients from 16 private dermatological practices in Greece, all treated with calcipotriol-betamethasone dipropionate gel. They were evaluated at the first visit and after 4 weeks. Moreover, they completed the Dermatology Life Quality Index (DLQI), while other data such as disease severity, subjective symptoms and adherence, were collected.

RESULTS

At week 4, the DLQI median was reduced by 3.5 points from the baseline (p<0.001; baseline and week 4 median: 4.5 and 1.0 respectively). Pruritus and sleep disorders also improved (p<0.001). Furthermore, 90.1% of the subjects fully adhered to treatment, with a 97.1% mean level of compliance.

CONCLUSIONS

The convincing clinical results, with a distinct improvement in HRQoL, plus the high level of adherence due to its advantageous physical properties, make the calcipotriol-betamethasone dipropionate gel formulation an important, effective and well-tolerated topical therapy to treat psoriasis.

Health-related quality of life in patients with psoriasis: a systematic review of the European literature

PURPOSE

To summarize the data published over the last 5 years in the European Union related to the health-related quality of life (HRQoL) of patients with psoriasis and its conditioning factors.

METHODS

International electronic databases and gray literature were searched to identify studies conducted on patient-reported outcomes in patients with psoriasis, published in Europe between January 1, 2009 and December 31, 2013. Bibliographic references were hand-searched. Editorials, letters, commentaries, opinion papers, and studies related to specific treatments were excluded.

RESULTS

A total of 46 studies met the inclusion criteria, 27 of them reporting data related to HRQoL or its conditioning factors. The publications reviewed highlighted the substantial negative impact of psoriasis on patients' HRQoL. Most of the studies that analyzed the relationship between HRQoL and sociodemographic characteristics described a relation between gender (female) and age (young patients) and poorer HRQoL. An association between HRQoL impairment and visibility of skin lesions and disease activity and severity was also established. Skin discomfort and pruritus were identified as elements that negatively influenced HRQoL. Use of biological agents had a positive impact on HRQoL and on treatment satisfaction, a better HRQoL being seen in patients treated with systemic therapies and biologics.

CONCLUSIONS

HRQoL has been broadly addressed in patients with psoriasis in Europe. Several disease- and patient-related factors contributed to its deterioration. Therapeutic measures with proven effectiveness in controlling disease symptoms and reducing PASI should be considered in patients with a severe disease who have a poorer HRQoL.

Measurement, Classification and Evaluation of Sleep Disturbance in Psoriasis: A Systematic Review

BACKGROUND

Psoriasis is a long-term immune-mediated inflammatory disorder mainly, but not only, affecting skin, and is associated with significant medical and psychological morbidity. Evidence suggests that sleep is disrupted in psoriasis, however high quality empirical evidence is lacking. Given the importance of sleep for health, characterisation of sleep disruption in psoriasis is an important goal. We therefore conducted a systematic review of the sleep-psoriasis literature.

METHODS

Searches were conducted in Pubmed, SCOPUS and Web of Science from inception to May 2016. Studies were compared against inclusion/exclusion criteria and underwent a quality evaluation. Given the heterogeneity of studies, we conducted a narrative synthesis of the findings.

RESULTS

Searches revealed 32 studies which met our predetermined inclusion/exclusion criteria. Whilst 93.7% of studies reported sleep disruption in this population, ranging from 0.05% to 85.4%, many had important methodological shortcomings. Over half of all quantitative studies (54.8%; 17/31) relied on non-validated measures, contributing to heterogeneity in study findings. In those that employed valid measures, assessing sleep was often not the primary objective. We frequently found the absence of adequate sample size calculations and poor statistical reporting.

CONCLUSION

This review showed that in psoriasis, reported sleep rates of sleep disturbance varied substantially. Most studies lacked a hypothesis driven research question and/or failed to use validated measures of sleep. We were unable to draw firm conclusions about the precise prevalence and nature of sleep disturbance within the psoriasis population. We offer suggestions to help advance understanding of sleep disturbance in psoriasis.

Psoriasis and sleep disorders: A systematic review

Psoriasis is an immune-mediated chronic inflammatory disorder which manifests as dermatologic lesions, and psoriatic arthritis (PsA) in about 30% of cases. Psoriasis is associated with multiple comorbidities including metabolic syndrome, hypertension, diabetes, cardiovascular events, obesity and psychiatric disorders, which can all affect the course of sleep disorders. A systematic review of the literature on the relationship between psoriasis, PsA, and formal sleep disorders identified 33 studies. There is an increased prevalence of obstructive sleep apnea (OSA) with 36%-81.8% prevalence in psoriasis versus 2%-4% in the general population. There was also an increase in the prevalence of restless legs syndrome of 15.1%-18% in psoriasis versus 5%-10% in European and North American samples. The wide variety of insomnia criteria used in studies resulted in an insomnia prevalence of 5.9%-44.8% in psoriasis, which is insufficient to show an elevated prevalence when the general population has a 10% prevalence of chronic insomnia and 30-35% prevalence of transient insomnia. There is evidence that symptoms of insomnia in psoriasis are directly mediated by pruritus and pain. Treatments that decrease the cutaneous symptoms in psoriasis were successful in mitigating insomnia, but did not show improvements in OSA where the relationship with psoriasis is multifactorial.

The experience of pain and redness in patients with moderate to severe plaque psoriasis

INTRODUCTION

The Psoriasis Symptom Inventory is a patient-reported outcome instrument that assesses severity of psoriasis signs and symptoms. In early qualitative research, patients reported pain related to psoriasis skin lesions and redness of affected areas of skin as key symptoms.

METHODS

Individual concept elicitation interviews and cognitive interviews were conducted in adults with moderate to severe plaque psoriasis. Interviews were audio-recorded and transcribed. Concepts were identified, coded and grouped by similar content using Atlas.ti software. Results were evaluated using qualitative research methods.

RESULTS

Of 30 patients recruited, 20 patients participated in concept elicitation interviews and 10 participated in cognitive interviews. Concept codes for skin pain and descriptions of color comprised 11% and 15%, respectively, of all symptom-related expressions. Of 90 pain-related expressions, 22 were about pain related to unconscious scratching and 68 were about pain from the psoriasis lesions. Of 199 color-related expressions, 72 were about red or reddish lesion color. Patients with darker skin tones were found to interpret redness consistently.

DISCUSSION

These results provide further support to content validity of pain and redness concepts in the Psoriasis Symptom Inventory.

CONCLUSIONS

Symptoms of skin pain and redness are highly relevant to patients with psoriasis.

Impact of functional pruritus compared with mild psoriasis on quality of life: a cross-sectional questionnaire study in Turkey

BACKGROUND

Functional pruritus (FP) is a type of chronic pruritus that is a somatoform disease in nature, triggered by psychogenic factors. Psoriasis is a chronic, inflammatory, and pruritic skin disease that causes significant cosmetic problems and psychological distress.

OBJECTIVE

In this study, we aimed to investigate the effects of functional pruritus on quality of life and to compare these with the effects of mild psoriasis.

METHODS

A total of 73 patients (40 with psoriasis and 33 with FP) were enrolled into the study. All the participants were asked to complete the Dermatology Life Quality Index (DLQI) and World Health Organization (WHO) Quality of Life, short form, Turkish version (WHOQOL-BREF-TR). Pruritus severity was evaluated subjectively with a visual analog scale (VAS) in both groups, and psoriasis severity was evaluated with the Psoriasis Area and Severity Index. Patients' age, gender, educational status, duration of disease, and medications were recorded.

RESULTS

There was no significant difference in quality of life between the two groups. VAS values were significantly higher in the FP group. A negative correlation was found between age and the physical domain on the WHOQOL-BREF-TR, and also between the psychological domain on the WHOQOL-BREF-TR and the duration of the disease in FP patients. In psoriasis patients, a negative correlation was found between age and DLQI scores.

CONCLUSION

FP has a negative impact on quality of life that is comparable to that of mild psoriasis. It seems that the visibility of psoriatic lesions and the cosmetic concerns in psoriasis patients do not result in a more severely impaired quality of life than in patients with FP.

Quality of life in psoriasis patients

Patient-reported outcomes are major components of decision making in clinical research, reimbursement, health policy and health care for psoriasis. The most important construct in patient-reported outcomes is health-related quality of life (HRQoL) which encompasses the individual's well-being with respect to health. HRQoL cannot directly be measured but is assessed in single dimensions, especially physical, emotional, social and functional aspects. For this, disease- and condition-specific instruments are used. Psoriasis is a chronic inflammatory disease affecting the skin as well as other tissues and organ systems. Patients suffer from a large scale of impairments, for example, physical symptoms, stigmatization and embarrassment, psychological strain and disabilities in profession. Improvement of HRQoL is a major objective of disease management. Current knowledge on determinants of HRQoL and the treatments available increase QoL in clinical care.

Limited evidence of the effects of patient education and self-management interventions in psoriasis patients: a systematic review

OBJECTIVE

To describe the contents of educational and self-management programmes for patients with psoriasis, and to evaluate their effects.

METHODS

A systematic review of randomized controlled trials (RCTs), quasi-randomized trials and controlled clinical trials identified by a systematic literature search. Risk of bias was assessed by two independent reviewers and interventional effects were summarized descriptively and by meta-analysis.

RESULTS

Nine studies were included, which ranged from single brief interventions to long complex multidisciplinary programmes. Four RCTs with adequate sequence allocation were included to analyze interventional effects. One RCT compared two different educational programmes and found no differences between groups. The results of three trials that focused on combinations of education and self-management were heterogeneous. One RCT based on a 12-week comprehensive programme reported statistically significant effects (p<0.05) on disease severity and health-related quality of life. Two RCTs with less comprehensive programmes reported no effects on HRQoL.

CONCLUSION

This review showed that little evidence is available to support the effects of educational and self-management interventions in patients with psoriasis that are studied in RCTs. There is a significant lack of focused self-management and, compared with other chronic conditions, there appear to be few effective disease-specific tailored educational programmes for psoriasis.