Stigmatization in Patients With Psoriasis: A Mini Review

Unmet Needs and Treatment Preference of Systemic Treatments for Moderate-to-Severe Psoriasis from the Perspectives of Patients and Dermatologists in China

INTRODUCTION

The treatment options for moderate to severe psoriasis (msPsO) in China have been greatly increased with the approvals of biologics. However, the unmet needs and treatment preferences of systemic treatments for msPsO in China remain unclarified.

METHODS

Fifty dermatologists and 300 patients with msPsO (41% with severe psoriasis) were surveyed for effectiveness, safety, treatment convenience, and treatment preferences (using a choice-based conjoint questionnaire). Descriptive statistics and conjoint simulation analyses were employed to summarize survey information and assess treatment preferences.

RESULTS

Both patients and dermatologists reported shorter treatment duration for oral drugs (2.7-6.2 months) than that for biologics (9.5-17.0 months). The most frequently reported treatment discontinuation reasons by the surveyed patients and dermatologists were unsatisfactory effectiveness (average 84.5%) for oral drugs and loss of efficacy over time (average 68.5%) for biologics. Commonly reported treatment inconveniences included regular lab tests for traditional oral drugs (average 71.5%) and administration assistance for biologics (average 58.0%). Injection site reactions (average 51.5%) and needle fear (average 35.5%) were frequently reported for biologics among the surveyed patients and dermatologists. Once-daily oral treatment was preferred over biweekly subcutaneous injection treatment when the two had comparable attributes (average in patients 87.1% vs. 12.9%; average in dermatologists 93.4% vs. 6.6%).

CONCLUSIONS

Unmet needs of systemic treatments remain for msPsO in China. Once-daily oral treatment is preferred over biweekly subcutaneous injections to treat msPsO when other treatment attributes are comparable.

Knowledge, Attitudes and Practices Towards Psoriasis Among Patients and Their Family Members

Purpose

KAP studies serve to enhance health consciousness and furnish foundational data for appraising, strategizing, and enacting disease management and prejudice eradication initiatives. There remains a dearth of published studies elucidating the dimensions of knowledge, attitudes, and practices among psoriasis patients in China. To investigate the knowledge, attitudes and practices (KAP) towards psoriasis among patients and their family members in Northern China.

Methods

This web-based, cross-sectional study was conducted among psoriasis patients and their family members through a self-administered questionnaire.

Results

Among patients (n=260), their mean KAP scores were 9.76±5.69 (range: 0-19), 35.64±11.48 (range: 14-70), and 56.73±10.98 (range: 16-80), respectively. Among family members (n=237), their mean KAP scores were 11.93±5.34 (range: 0-19), 35.80±4.34 (range: 8-40), and 37.04±4.38 (range: 8-40), respectively. Structural equation modeling (SEM) analysis for patients indicated significant and negative path relations between knowledge and attitudes (β=-2.271, P<0.001), and between knowledge and practice (β=-0.398, P<0.001). Extended SEM analysis, which divides knowledge into K1, K2, and K3 parts, showed negative path relations between K3 and attitude (β=-1.300, P=0.002), between attitude and practice (β=-0.634, P<0.001). Moreover, SEM for family members showed positive path relations between knowledge and attitude (β=1.536, P<0.001), between attitude and practice (β=0.682, P<0.001).

Conclusion

Patients in Northern China demonstrated insufficient knowledge, negative attitude, and proactive practice, while their family members had insufficient knowledge, positive attitude, and proactive practice toward psoriasis. It is recommended to implement educational interventions addressing knowledge gaps among patients and families.

Reduced economic disparity in biologics use for psoriasis after introducing the reducing copayment program

Biologics for psoriasis are efficient and safe, but very expensive. We investigated the association of the reducing copayment program (RCP) with changes in biologics use patterns depending on the income levels of patients with moderate-to-severe psoriasis. This nationwide cohort study included patients identified as having moderate-to-severe psoriasis between 2014 and 2020. Logistic regression models were used to estimate the odds ratio for the use of biologics according to income levels. Among 57,139 patients with moderate-to-severe psoriasis, 3464 (6.1%) used biologics for psoriasis from 2014 to 2020. After the introduction of RCP in 2017, the proportion of patients with moderate-to-severe psoriasis using biologics rapidly increased from 5.0% in 2016 to 19.2% in 2020; the increase was more remarkable in patients with the lowest or mid-low income compared to those with Medical Aid. Drug survival of biologics was higher in patients with the highest income before the RCP, but became comparable between those with high and low incomes after RCP introduction. The introduction of RCP was associated with an increased use of biologics in patients with moderate-to-severe psoriasis of all income levels; however, the effect was more pronounced in low-income patients. The RCP may contribute to alleviating the disparity in access to biologics.

Safety, tolerability, pharmacokinetics and efficacy of HB0017, a humanized monoclonal antibody that targets interleukin-17A, in healthy participants and patients with moderate-to-severe plaque psoriasis

BACKGROUND

Several interleukin (IL)-17 inhibitors have been approved for the treatment of moderate-to-severe plaque psoriasis (PsO). There is still scope for the development of affordable treatments for PsO.

OBJECTIVES

To assess, in a phase Ia study, the safety, tolerability and pharmacokinetics (PK) of HB0017, a humanized monoclonal antibody that targets IL-17A, in healthy participants and patients with moderate-to-severe plaque PsO; and, in a phase Ib study, to assess the efficacy of HB0017 in patients with moderate-to-severe plaque PsO.

METHODS

The phase Ia study (NCT04505033) was a randomized double-blind placebo-controlled dose-escalation study in healthy participants. Each cohort of 10 volunteers was randomly assigned to receive either a single dose of HB0017 (50 mg, 150 mg, 300 mg or 450 mg) or the matching placebo at a ratio of 4 : 1. The phase Ib study (NCT05442788) was a randomized double-blind placebo-controlled dose-escalation study in enrolled patients with moderate-to-severe plaque PsO. Each cohort of 10 patients was randomly assigned to receive either multiple doses of HB0017 (150 mg, 300 mg or 450 mg) or the matching placebo at a ratio of 4 : 1.

RESULTS

HB0017 demonstrated dose-proportional linear PK and was tolerated across the dose range assessed. In the phase Ia and Ib studies, participants in both the HB0017 and placebo groups experienced treatment-emergent adverse events (69% vs. 87%, 96% vs. 100%, respectively). HB0017 demonstrated clinically meaningful effects in patients with moderate-to-severe plaque PsO. PASI 75 [≥ 75% improvement in Psoriasis Area and Severity Index (PASI)], PASI 90 (≥ 90% improvement in PASI) and static Physician Global Assessment (sPGA) 0/1 (i.e. 'clear' or 'almost clear') responses were 100% for the HB0017 300-mg group, with maximal improvements (100% or near 100% reductions from baseline) in PASI score observed at week 12, while the duration of effect was evident up to week 20. There was no clinical response in any participant in the placebo group in the phase Ib study.

CONCLUSIONS

Overall, HB0017 showed acceptable safety and tolerability in both healthy participants and patients with moderate-to-severe plaque PsO. An encouraging signal of efficacy with a longer half-life provides HB0017 with the potential to be added to the currently available range of biologics targeting IL-17A.

Skin-Related Sexual Life Questionnaire (SRSLQ): Creation and Validation of the Questionnaire

Background and Objectives: The assessment of sexual dysfunction among psoriatic patients still remains a great diagnostic difficulty due to its subjective and embarrassing character. Various questionnaires have been used to assess sexual dysfunctions associated with skin conditions; however, none of them have been approved as a gold standard. The aim of our study was to create and validate the Skin-Related Sexual Life Questionnaire (SRSLQ) for the assessment of possible sexual dysfunction and related psychological burdens in patients with skin diseases. Materials and Methods: A total of 109 patients, including 45 women and 64 men (1:1.4) suffering from psoriasis and aged between 18 and 73 years (mean 48.0 ± 13.4 years), were included in the study. All subjects completed the 11-item SRSLQ and the Dermatology Life Quality Index (DLQI). In addition, all men were asked to fulfil the five-item version of the International Index of Erectile Dysfunction (IIEF-5) at the time of examination and 7 days after enrollment. The disease severity was assessed via the PASI scale. Results: The statistical analysis of internal consistency of SRSLQ showed very good integrity, with a Cronbach α coefficient of 0.94. The reproducibility level assessed with intraclass correlation coefficient (ICC) amounted to 0.96. A significant correlation between the total score of the 11-item SRSDQ and the DLQI (r = 0.39; p < 0.001) was found, confirming congruent validity. Conclusions: The validated 11-item Skin-Related Sexual Life Questionnaire can be successfully implemented in daily clinical practice as well as in clinical research.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Quality of life and stigmatization in people with skin diseases in Europe: A large survey from the 'burden of skin diseases' EADV project

BACKGROUND

Several large studies on the burden of skin diseases have been performed in patients recruited in hospitals or clinical centres, thus missing people with skin diseases who do not undergo a clinical consultation.

OBJECTIVES

To evaluate the burden of the most common dermatological diseases in adult patients across Europe, in terms of quality of life, work life, and stigmatization.

METHODS

Population-based survey on a representative sample of the European general population aged 18 years or older. Participants who declared to have had one or more skin problem or disease during the previous 12 months completed the Dermatology Life Quality Index questionnaire, and answered questions regarding the impact of their skin disease on daily and work life, anxiety/depression, and stigmatization.

RESULTS

The study population included 19,915 individuals, 44.7% of whom were men. Quality of life was particularly impaired in people with hidradenitis suppurativa (HS), and sexually transmitted diseases. About a half of participants with acne, alopecia, or chronic urticaria, and about 40% of those with atopic dermatitis (AD), skin cancers, or psoriasis reported a modest to extremely large effect of the disease on their quality of life. Overall, 88.1% of participants considered their skin disease as embarrassing in personal life and 83% in work life. About half of the respondents reported sleeping difficulty, feeling tired, and impact of the disease on taking care of themselves. Concerning stigmatization, 14.5% felt to have been rejected by others because of the skin disease, and 19.2% to have been looked at with disgust. Anxiety and depression were frequently reported by patients with all the diseases.

CONCLUSIONS

Skin diseases may heavily affect patients' daily and work life, and cause feelings of stigmatization. An early intervention is needed to avoid consequences on the patients' life course.

Patient Needs in Psoriasis Treatment and their Influencing Factors: A Nationwide Multicentre Cross-Sectional Study in China

Background

The management and treatment of psoriasis has rarely considered patient needs, which are numerous, multi-dimensional and are of great importance to improving treatment outcomes.

Objectives

This study aimed to evaluate and compare the patients' needs for psoriasis treatment and identify factors predicting the need to make patient-centred decisions about treatment.

Materials and Methods

This nationwide multicentre cross-sectional study included subjects between October 2020 and August 2021. The status quo of the needs in psoriasis treatment and their influencing factors were analysed mainly using the Chi-square test and binary logistic regression.

Results

Information on sociodemographic and clinical characteristics were obtained. Factor analysis of a specially designed questionnaire showed that rapid skin clearance, reduced treatment expense and fewer hospital visits or treatment time were the first three patient needs in psoriasis treatment. Several influencing factors were important including the sociodemographic characteristics of gender, marital status, education level and family history, special location of skin lesions, dermatology life quality index (DLQI), Investigator's Global Assessment modified 2011 (IGA mod 2011), condition of the episode, clinical type of psoriasis, seasonal exacerbation and therapy.

Conclusions

Patients with psoriasis pursued a wide range of treatment goals, with the most desired being rapid skin clearance, reduced treatment expense and time-saving. Paying attention to sex, marital status, education level, the special location of skin lesions and the DLQI will help dermatologists develop patient-centred treatment, meet the patient's needs and eventually improve the treatment outcomes.

A network analysis of psychological flexibility, coping, and stigma in dermatology patients

Introduction

Despite the negative effects of stigma in individuals with skin conditions, interventions to address its effects are rare. This might be in part due to a continued lack of understanding as to how individuals respond to stigma.

Methods

In this study, we employed a step-case analytic method, using traditional regression, moderation, and network analyses, to examine the role of psychological flexibility (PF) with stigmatized experiences, and stigma-related outcomes. We run a cross-sectional study (n = 105 individuals with various skin conditions) and analyzed stigma-related variables. We included variables examining perceived stigmatization (PSQ), anxiety (GAD-7), depression (PHQ-9), well-being (EQ5D5L), and variables stemming from the PF model (CompACT), presented as three coping with stigma responses, namely "open," "aware," and "active.".

Results

Using network analysis, the most influential or central variables that contributed to stigma were generalized anxiety, perceived stigmatization, and valued actions. In relation to PF, being open to the experience of stigma (as opposed to avoidance), keeping a distance from stigmatized thoughts (as opposed to self-stigmatizing), and bringing attention to value-based committed actions (as opposed to passivity) were all found to contribute to less stigmatized experiences.

Discussion

The results indicate that two of the three skills of the PF model ("open" and "active") may be important targets for interventions targeting stigma in people living with skin conditions.

Mediating role of resilience in the relationship between COVID-19 related stigma and mental health among COVID-19 survivors: a cross-sectional study

BACKGROUND

The global coronavirus disease 2019 (COVID-19) has caused many negative effects on physical and mental health of patients who have survived COVID-19. Apart from some long-lasting physical sequelae, those COVID-19 survivors are also suffering stigma and discrimination at different levels around the world. The current study aims to assess the role resilience played in stigma and mental disorders among COVID-19 survivors.

METHODS

The cross-sectional study was carried out among former COVID-19 patients in Jianghan District (Wuhan, China) from June 10 to July 25, 2021. The demographic questions, the Impact of Events Scale-Revised, the Generalized Anxiety Disorder Questionnaire, the Patient Health Questionnaire, the Resilience Style Questionnaire and the Short Version of COVID-19 Stigma Scale of 12 items were used to collect relevant information of the participants. Descriptive analyses, Pearson correlation analysis and Structural Equation Modeling were used to make data description and analysis.

RESULTS

A total of 1541 out of 1601 COVID-19 survivors (887 females and 654 males) were included in the analysis. Perceived stigma of those COVID-19 survivors correlates significantly with anxiety (r = 0.335, P < 0.001), depression (r = 0.325, P < 0.001) and post-traumatic stress disorder (PTSD) (r = 0.384, P < 0.001). It has a direct effect on COVID-19 survivors' anxiety (β = 0.326, P < 0.001), depression (β = 0.314, P < 0.001), PTSD (β = 0.385, P < 0.001) and their resilience (β = - 0.114, P < 0.01). Resilience partially mediated the association between perceived stigma and anxiety (β = 0.020, P < 0.01), depression (β = 0.020, P < 0.01), and PTSD (β = 0.014, P < 0.01) among COVID-19 survivors.

CONCLUSION

Stigma has a significant negative impact on mental health, while resilience plays a mediator role in the relationship between stigma and mental health among COVID-19 survivors. Based on our study, we suggested that when designing psychological interventions for COVID-19 survivors, consideration should be taken into account to reduce stigma and improve resilience.

Facial acne causes stigmatization among adolescents: A cross-sectional study

BACKGROUND

Stigmatization is defined as a discrediting mark which sets the person from others and hindering interpersonal relationships. Literature data on stigma in acne subjects are scarce.

AIMS

This study was undertaken to assess feelings of stigmatization in adolescents with facial acne.

MATERIAL/METHODS

The study was performed on 730 high-school students aged 15 to 19 years with the mean age of 17.05 ± 1.18 years. Self-reported acne was found in 74.9% of subjects. The severity of acne was self-assessed with the standardized color images based on Investigators Global Assessment (IGA). Stigmatization was studied with 6-Item Stigmatization Scale (6-ISS) and Perceived Stigmatization Questionnaire (PSQ). Additionally, quality of life (QoL) was evaluated with Dermatology Life Quality Index (DLQI).

RESULTS

58% of adolescents with acne presented with feelings of stigmatization. Within the acne population, stigmatization was significantly more common in females than in males (p < 0.001). The mean level of stigmatization according to 6-ISS was significantly higher in acne sufferers than in those free from acne (1.68 ± 2.42 points and 0.55 ± 1.50 points, respectively; p < 0.001). Feelings of stigmatization were significantly more pronounced by females than males (p < 0.001). Staring at the skin and the fact that others are not attracted to person due to skin lesions were main problems raised by the study participants with acne. 6-ISS scores correlated with acne severity (r = 0.278; p < 0.001) and both 6-ISS and PSQ scores with QoL impairment (r = 0.530; p < 0.001 and r = 0.341; p < 0.001, respectively).

CONCLUSIONS

Facial acne is a highly stigmatized skin disease and requires a holistic therapeutic approach.

The Implication of Misinformation and Stigma in Age-Related Quality of Life, Depression, and Coping Mechanisms of Adult Patients with Psoriasis

Background and Objectives: Stigma and lack of acceptance in society might have detrimental effects on the quality of life of patients with psoriasis, sometimes being comparable with other chronic diseases and conditions that affect the appearance of a patient, such as burns. Therefore, we surveyed our patients diagnosed with psoriasis to determine the implications of misinformation and stigma for their quality of life, depression, and coping strategies stratified by different age categories. Materials and Methods: A cross-sectional study was designed for a sample size of a minimum of 45 patients considering a prevalence of psoriasis of 2–3% in the general population. The study participants (patients and controls) were given both a paper-based unstandardized questionnaire and an online version of three standardized surveys. The cohort of patients was further split into three age groups to determine their age-related quality of life and coping mechanisms. Results: The proportion of patients with a history of depression and depressive symptoms among patients with psoriasis was significantly higher. Multiple discrepancies were observed between patients and controls regarding questions that targeted stigma and misinformation. On the Coping Orientation to Problems Experienced Inventory (COPE-60) questionnaire, older patients were more likely to use positive coping mechanisms such as engagement and problem-focused coping, while the young patients were using more emotion-focused coping mechanisms. However, patients in the 30–50 age range group scored the highest on physical and mental health among all participants who filled the 12-Item Short Form Survey (SF-12) survey. The Dermatology Life Quality Index (DLQI) results showed significantly more patients answering “a lot and very much” concerning embarrassment and social activities, while sexual difficulties affected the older patients. The strongest correlations with depression were observed in the young patient group, who believed that psoriasis can cause skin cancer (rho = 0.418) and who had sexual difficulties (rho = 0.414) and embarrassment (rho = 0.359) as evaluated by the DLQI survey. In the 30- to 50-year-old group, the strongest correlations were with the feeling of being stigmatized (rho = 0.376), having sexual difficulties (rho = 0.367) and disengagement coping style (rho = 273). Conclusions: While the respondents are reasonably well-informed regarding psoriasis, a degree of stigma remains, likely due to involuntary emotional responses such as repulsion and embarrassment. It is essential to establish initiatives aimed at educating the general public, raising awareness, and establishing a more tolerant social environment for psoriasis patients.