[Stigmatization and quality of life of patients with psoriasis and atopic dermatitis]

Patient Unique Stigmatization Holistic tool in dermatology (PUSH-D): Development and validation of a dermatology-specific stigmatization assessment tool

BACKGROUND

The skin plays an important role in establishing interpersonal relationships, and thus visible skin disorders, which have a significant impact on physical appearance, influence other people's behaviours and attitudes.

OBJECTIVE

To develop and validate a dermatologic-specific questionnaire to evaluate stigmatization in individuals with visible skin conditions.

METHODS

Items were generated by a verbatim report based on qualitative interviews with patients with various dermatologic conditions. Subsequently, a study was implemented for psychometric analysis. A dermatology-specific stigmatization questionnaire (PUSH-D) was refined via item reduction according to inter-question correlations, consensus among experts and exploratory factor analysis. Internal consistency was determined by calculating Cronbach's α. Concurrent validity was determined by calculating the correlation between PUSH-D and the Dermatology Life Quality Index (DLQI) and the Rosenberg Self-Esteem Scale (RSES).

RESULTS

From a primary list of 22 items, PUSH-D was reduced to a 17-item questionnaire, covering two pertinent dimensions based on the exploratory factor analysis. Construct validity was demonstrated, and PUSH-D showed good internal consistency (Cronbach's α = 0.9). PUSH-D correlated strongly with the DLQI 0.72 (p < 0.001) and moderately with the RSES 0.49 (p < 0.001).

CONCLUSION

PUSH-D allows a comprehensive view of the degree of stigmatization in visible skin disorders, as well as the comparability of stigmatization levels across various skin conditions.

Stigmatization in Patients With Psoriasis: A Mini Review

Psoriasis is a chronic and recurrent immune-related skin disease that often causes disfigurement and disability. Due to the visibility of lesions in patients and inadequate understanding of dermatology knowledge in the general public, patients with psoriasis often suffer from stigma in their daily lives, which has adverse effects on their mental health, quality of life, and therapeutic responses. This review summarized the frequently used questionnaires and scales to evaluate stigmatization in patients with psoriasis, and recent advances on this topic. Feelings of Stigmatization Questionnaire, Questionnaire on Experience with Skin Complaints, and 6-item Stigmatization Scale have been commonly used. The relationship between sociodemographic characteristics, disease-related variables, psychiatric disorders, quality of life, and stigmatization in patients with psoriasis has been thoroughly investigated with these questionnaires. Managing the stigmatization in patients with psoriasis needs cooperation among policymakers, dermatologists, psychologists, psychiatrists, researchers, and patients. Further studies can concentrate more on these existing topics, as well as other topics, including predictors of perceived stigmatization, stigmatization from non-patient groups, influence of biologics on stigmatization, and methods of coping with stigmatization.

Assessment of stigma related to visible skin diseases: a systematic review and evaluation of patient-reported outcome measures

Misconceptions about visible skin diseases are widespread, and patients often face discrimination and stigmatization due to their condition. The associated negative health and psychosocial consequences of stigmatization in skin diseases have prompted an increase in research activity in recent times, resulting in a wide variety of assessment measures. This study aimed at aggregating and evaluating evidence of psychometric properties and methodological quality of published measures to assess stigma in visible skin diseases. Studies assessing stigmatization in visible skin diseases were searched in four databases (Medline, PsycINFO, Web of Science and Embase) until February 2021. The review followed PRISMA guidelines. Papers regarding development and/or validation of measures were identified by two independent researchers. Inclusion criteria were defined as follows: (i) quantitative studies in (ii) populations with skin diseases using (iii) questionnaires explicitly assessing (iv) perceived or public stigmatization or discrimination available in (iv) English or German language. The COnsensus-based Standards of health Measurement INstruments (COSMIN) checklist was used to evaluate their psychometric properties and risk of bias. 35 studies using 21 instruments were identified. Twenty instruments focused on assessing the perceived reality of those affected by visible skin diseases, while public stigma was only assessed by two instruments. Twelve scales could be recommended for use, while nine instruments had the potential to be recommended after further studies have assessed their quality. Some limitations are to be noted. Only studies in English and German were included. Research on self-constructed instruments can lead to new validated instruments, but they were not included in the review at this point. Several validated instruments could be recommended for use. Future research is needed regarding the assessment of stigma across different visible skin diseases, in children and adolescents, and in the general public.

Anticipated and Perceived Stigma Among Patients With Psoriasis

BACKGROUND

Perceived stigma among patients with psoriasis (PWP) is associated with poorer quality of life.

OBJECTIVE

To determine the prevalence and predictors of stigmatizing attitudes that PWP expect and experience from others.

METHODS

We conducted a survey using validated outcome measures to assess the extent to which PWP anticipate and perceive stigma from others. Demographic and clinical characteristics were obtained from electronic medical records.

RESULTS

Patients (n = 106) were 48.11% female, 70.75% white, and had a mean age ± SD of 47.90 ± 16.19 years old. Of all, 25.47% self-reported their psoriasis as severe. Mean physician global assessment score ± SD was 2.98 ± 1.81. Two-thirds (66.98%) of patients reported that, in response to seeing their psoriasis-affected skin, they anticipated others to stereotype them as "contagious." Linear regression analyses demonstrated that patient-reported severe psoriasis, compared to mild psoriasis, was associated with greater anticipation of negative stereotypes, social avoidance, and perceived stigma from others (P values < .05). Physician-measured body surface area and global assessment scores were not significantly associated with any outcome.

CONCLUSION

Prevalence of anticipated and perceived stigma among PWP is high. Our results suggest that objective measures of severity may not identify patients at risk of stigma-related distress. Additional methods, such as directly inquiring about stigmatizing experiences, may be needed.

[German version of the Skin Shame Scale (SSS-24) : Validation with dermatological patients and dermatologically healthy individuals]

BACKGROUND

Skin shame plays an important role in the psychological distress of dermatological patients. However, it is rarely examined in research or clinical practice due to the lack of availability of a robust measure of skin shame. This study sought to adapt and validate the Skin Shame Scale (SSS-24) for use in the German-speaking population.

METHODS

The SSS-24 questionnaire was completed by 488 dermatologically healthy (DH) individuals (66.6% women) and 339 dermatological patients (DP; 66.7% women). Participants also completed measures of general shame (SHAME) and of psychological distress (BSI[Brief Symptom Inventory]-18).

RESULTS

The SSS-24 showed adequate psychometric properties and a high internal consistency in both samples (DH: α = 0.91; DP: α = 0.95). DP reported more skin shame than DH (p < 0.001) but in both samples more skin shame was associated with more general shame and more psychological distress (p < 0.001).

CONCLUSIONS

Overall, the psychometric properties of the English original version were replicated in the German version of the SSS-24. Due to the strong associations with general shame and psychological distress, skin shame should be considered an important parameter in psychodermatology. The SSS-24 enables further research into the role of shame in skin conditions and provides a useful tool for identifying patients who might benefit from psychosocial interventions.

Patient-Reported Outcome Instruments for Surgical and Traumatic Scars: A Systematic Review of their Development, Content, and Psychometric Validation

BACKGROUND

Patient-reported outcomes (PROs) are of growing importance in research and clinical care and may be used as primary outcomes or as compliments to traditional surgical outcomes. In assessing the impact of surgical and traumatic scars, PROs are often the most meaningful. To assess outcomes from the patient perspective, rigorously developed and validated PRO instruments are essential.

METHODS

The authors conducted a systematic literature review to identify PRO instruments developed and/or validated for patients with surgical and/or non-burn traumatic scars. Identified instruments were assessed for content, development process, and validation under recommended guidelines for PRO instrument development.

RESULTS

The systematic review identified 6534 articles. After review, we identified four PRO instruments meeting inclusion criteria: patient and observer scar assessment scale (POSAS), bock quality of life questionnaire for patients with keloid and hypertrophic scarring (Bock), patient scar assessment questionnaire (PSAQ), and patient-reported impact of scars measure (PRISM). Common concepts measured were symptoms and psychosocial well-being. Only PSAQ had a dedicated appearance domain. Qualitative data were used to inform content for the PSAQ and PRISM, and a modern psychometric approach (Rasch Measurement Theory) was used to develop PRISM and to test POSAS. Overall, PRISM demonstrated the most rigorous design and validation process, however, was limited by the lack of a dedicated appearance domain.

CONCLUSIONS

PRO instruments to evaluate outcomes in scars exist but vary in terms of concepts measured and psychometric soundness. This review discusses the strengths and weaknesses of existing instruments, highlighting the need for future scar-focused PRO instrument development.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Perceived Stigma in Patients with Alopecia and Mental Disorder: A Comparative Study

Aim:

We aimed to measure the perceived stigma, especially in patients with alopecia areata (AA) and to compare the results with patients with mental disorder (MD).

Materials and Methods:

This study included forty patients with AA who were consecutively recruited from dermatology outpatient clinic and 42 patients with MD who were consecutively recruited from psychiatric outpatient clinic. The presence of a MD was assessed by the Diagnostic and Statistical Manual of Mental Disorder Fourth Edition. All participants were asked to complete the 28 items modified stigmatization questionnaire.

Results:

Total and all subscale scores of stigmatization questionnaire scale were higher in the group of patients with AA than in the patients with MD.

Conclusion:

AA is a condition that leads to more self-stigmatization than MD.

Chinese herbal medicine for atopic eczema

BACKGROUND

Chinese herbal medicine (CHM) has been increasingly used for atopic eczema. A previous version of this Cochrane review published in 2004 found some evidence of a possible benefit for oral ingestion of CHM for eczema, but the results were inconclusive and the evidence needs to be updated. We have expanded the scope of this review to include an assessment of the topical and oral effects of CHM for eczema.

OBJECTIVES

To assess the effects of oral ingestion and topical applications of CHM for the management of eczema in children and adults.

SEARCH METHODS

We searched the following databases up to September 2012: the Cochrane Skin Group Specialised Register, CENTRAL in The Cochrane Library (2012, Issue 8), MEDLINE (from 1946), EMBASE (from 1974), AMED (from 1985), LILACS (from 1982), and CINAHL (from 1981). We searched the following from inception: SCOPUS, HERBMED, ProQuest, CQVIP, CNKI, and Wanfang Data. We also searched trials registers, handsearched conference proceedings, checked the reference lists of all included and excluded studies and review articles for further references to relevant trials, and contacted experts in Chinese medicine for unpublished studies.

SELECTION CRITERIA

All randomised controlled trials (RCTs) in children and adults with eczema comparing CHM to placebo; no intervention; active controls, including acupuncture; or conventional medicines.

DATA COLLECTION AND ANALYSIS

Two authors selected the RCTs, extracted data, and assessed quality independently. We contacted study authors for missing data. We collected adverse events from the included studies.

MAIN RESULTS

We included 28 studies, with a total of 2306 participants. We assessed most of the studies at high 'risk of bias', particularly in blinding of participants and personnel, and there was substantial inconsistency between studies, so any positive effect of CHM must be treated with caution. We did not include the four studies from the previous version in this review, because they investigated a CHM product that has been withdrawn from the market since 2004.Four studies (three oral and one topical) compared CHM to placebo. Pooled data from 2 studies showed the total effectiveness rate in the CHM group was higher (by risk ratio (RR) 2.09, 95% confidence interval (CI) 1.32 to 3.32; 2 studies; n = 85), and the itching visual analogue score (VAS) in the CHM group was 1.53 lower (by standardised mean difference (SMD), 95% CI 2.64 to 0.41; 2 Studies; n = 94) than the placebo group, where a lower VAS score indicates reduced itch. One study of 85 participants with moderate to severe eczema who received an oral CHM formula for 12 weeks reported a quality of life (QoL) score 2.5 lower in the CHM group (by difference in means (MD), 95% CI 4.77 to 0.23; 1 study; n = 85) than the placebo group, where a lower score indicates better QoL.  Twenty-two studies and 1 arm from a study with a 4-arm parallel controlled design compared CHM (5 oral, 6 topical, and 12 mixed oral and topical) to conventional medicines. The total effectiveness rate in the CHM groups was superior (RR 1.43, 95% CI 1.27 to 1.61; 21 studies; n = 1868; very low quality evidence), and the itching VAS in the CHM groups was 0.83 lower (SMD, 95% CI 1.43 to 0.22; 7 studies; n = 465) than the comparators.Two studies compared combined oral and topical CHM to the same oral CHM formula alone. The total effectiveness rate in 1 study was not statistically significant (RR 1.13, 95% CI 0.78 to 1.63; 1 study; n = 20). In the other study, the itching VAS in the CHM group was 1.05 lower (MD, 95% CI 1.75 to 0.35; 1 study; n = 23) than the control group.With regard to side-effects, four studies did not give any report of adverse events. The other 24 studies reported minor adverse events, which were reversed soon after stopping CHM. One participant withdrew from one trial because of exacerbation of their condition after using the CHM intervention.Eight studies received government funding.

AUTHORS' CONCLUSIONS

We could not find conclusive evidence that CHM taken by mouth or applied topically to the skin could reduce the severity of eczema in children or adults.Well-designed, adequately powered RCTs are needed to evaluate the efficacy and safety of CHM for managing eczema.

Dyadic adjustment, family coping, body image, quality of life and psychological morbidity in patients with psoriasis and their partners

BACKGROUND

Psoriasis is an incurable and chronic disease that includes unpredictable periods of remission and relapse requiring long-term therapy.

PURPOSE

This paper focuses on the relationship among family coping, psychological morbidity, body image, dyadic adjustment and quality of life in psoriatic patients and their partners.

METHOD

One hundred and one patients with psoriasis and 78 partners comprised the sample. They were regular users of the Dermatology Service of a Central Northern hospital in Portugal and a private dermatology clinic. Patients with psoriasis were assessed on anxiety, depression, body image, quality of life, dyadic adjustment and family coping. Partners were assessed on the same measures except body image and quality of life.

RESULTS

A positive relationship among dyadic adjustment, psychological morbidity and family coping in patients and their partners was found. Also, patients with lower levels of quality of life had partners with higher levels of depressive and anxious symptoms. Better dyadic adjustment predicted family coping in the psoriatic patient. High levels of dyadic adjustment in patients and low partners' trait anxiety predicted better dyadic adjustment in partners.

CONCLUSION

The results highlight the importance of incorporating family variables in psychological interventions in psoriasis' care, particularly family coping and dyadic adjustment as well as the need for psychological intervention to focus both on patients and partners.

Summary of the International Federation of Psoriasis Associations (IFPA) meeting: a report from the GRAPPA 2009 annual meeting

The International Federation of Psoriasis Associations (IFPA) organized the second World Psoriasis and Psoriatic Arthritis Conference in Stockholm, Sweden, in June 2009. The 2009 collaborative multidisciplinary meeting attracted nearly 1000 clinicians and investigators from dermatology, rheumatology, basic science, and industry, as well as patients and leaders of patient organizations, from 68 countries. The major theme of the meeting was "Psoriasis - Skin and Beyond," and the primary aim was to highlight the significant effects of psoriasis and related comorbidities on patient function and quality of life. The annual meeting of GRAPPA (Group for Research and Assessment of Psoriasis and Psoriatic Arthritis) was held concurrently, and several GRAPPA members attended both meetings. Key presentations at IFPA that GRAPPA members believed were highlights of that meeting are summarized here.

Is atopic disease a risk factor for attention-deficit/hyperactivity disorder? A systematic review

The increase in prevalence and burden of atopic diseases, i.e. eczema, rhinitis, and asthma over the past decades was paralleled by a worldwide increase in attention-deficit/hyperactivity disorder (ADHD) diagnoses. We systematically reviewed epidemiologic studies investigating the relationship between atopic diseases and ADHD. Electronic literature search in PubMed and PsycINFO (until 02/2010) supplemented by handsearch yielded 20 relevant studies totaling 170,175 individuals. Relevant data were abstracted independently by two reviewers. Six studies consistently reported a positive association between eczema and ADHD with one study suggesting effect modification by sleeping problems. Twelve studies consistently found a positive association between asthma and ADHD, which, however, appeared to be at least partly explained (confounded) by concurrent or previous eczema. Rhinitis and serum-IgE level were not related to ADHD symptomatology. We conclude that not atopic disease in general, but rather that eczema appears to be independently related to ADHD. Conclusions about temporality and whether the observed association constitutes a causal relationship are impossible, as most studies were cross-sectional (n = 14; 70%) or case-control studies without incident exposure measurement (n = 5; 25%). Another methodological concern is that the criteria to define atopic disease and ADHD were inadequate in most studies. A failure to adjust for confounders in the majority of studies was an additional limitation so that meta-analysis was not indicated. Future interdisciplinary high-quality prospective research is needed to better understand the mechanisms underlying the relationship between eczema and ADHD and to eventually establish targeted preventive and treatment strategies.

Psoriasis: is the impairment to a patient's life cumulative?

Psoriasis is associated with significant physical and psychological burden affecting all facets of a patient's life--relationships, social activities, work and emotional wellbeing. The cumulative effect of this disability may be self-perpetuating social disconnection and failure to achieve a 'full life potential' in some patients. Health-related quality of life studies have quantified the burden of psoriasis providing predominantly cross-sectional data and point-in-time images of patients' lives rather than assessing the possible cumulative disability over a patient's lifetime. However, social and economic outcomes indicate there are likely negative impacts that accumulate over time. To capture the cumulative effect of psoriasis and its associated co-morbidities and stigma over a patient's life course, we propose the concept of 'Cumulative Life Course Impairment' (CLCI). CLCI results from an interaction between (A) the burden of stigmatization, and physical and psychological co-morbidities and (B) coping strategies and external factors. Several key aspects of the CLCI concept are supported by data similar to that used in health-related quality of life assessments. Future research should focus on (i) establishing key components of CLCI and determining the mechanisms of impairment through longitudinal or retrospective case-control studies, and (ii) assessing factors that put patients at increased risk of developing CLCI. In the future, this concept may lead to a better understanding of the overall impact of psoriasis, help identify more vulnerable patients, and facilitate more appropriate treatment decisions or earlier referrals. To our knowledge, this is a first attempt to apply and develop concepts from 'Life Course Epidemiology' to psoriasis research.

[Suicidal ideation, anxiety and depression in adult patients with atopic dermatitis]

BACKGROUND

Atopic dermatitis is a chronic skin disease which is increasing in incidence and prevalence. An understanding of the mental burden patients carry is essential for successful psychodermatological treatment.

PATIENTS AND METHODS

62 adult atopic dermatitis patients were tested with a questionnaire and compared with a matched group of 62 healthy persons. Using the questionnaire for assessing suicide risk of Pöldinger, suicidal ideations were assessed. Anxiety and depression were detected by using HADS-D; the severity of symptoms by patients' self-evaluation based on SCORAD index. Finally, the onset of atopic dermatitis was established.

RESULTS

A significantly higher level of suicidal ideation, anxiety and depression was shown among patients with atopic dermatitis. All three aspects showed a medium effect size. Strong correlations between severity of symptoms and psychological burden were observed. 16.1% of patients with atopic dermatitis suffered from suicidal ideation, while only 1.6% in control group did, producing an odds ratio of 11.73 (95%CI 1.45-94.71).

CONCLUSION

Suicidal ideation, anxiety and depression are important factors, which should be addressed when treating atopic dermatitis.

The Dermatology Life Quality Index 1994-2007: a comprehensive review of validation data and clinical results

BACKGROUND

The Dermatology Life Quality Index (DLQI) is one of the most widely used dermatology-specific quality of life instruments. Over the last 5 years there has been great interest in its use.

OBJECTIVES

To collect and present all information regarding the technical properties and the clinical use of the DLQI from the date it was published to the end of 2007 for use as a single source of reference.

METHODS

A detailed literature search was conducted using electronic reference databases and the DLQI library in the Department of Dermatology, Cardiff University. All publications mentioning any aspect of the DLQI, from the time of its development to the end of 2007, were identified and the data concerning the DLQI in terms of its psychometric analysis, and use in clinical trials, epidemiological studies and health services research, were extracted and tabulated with all the relevant references.

RESULTS

In total, 272 full articles which have included the DLQI were reviewed. Studies described in these articles were divided into five main categories: psychometric studies, descriptive/epidemiological studies, drug (topical and systemic) trials, clinical practice research, and therapeutic interventions. The DLQI has been used in 33 different skin conditions in 32 countries and is available in 55 languages. Psychometric aspects of the DLQI such as validity, reliability, responsiveness to change, factor structure, and minimal important difference were described in 115 studies. The DLQI has been used in 33 studies assessing the effectiveness of 14 different types of therapeutic interventions and in 37 studies evaluating nine types of clinical practice research. Sixty studies have used it alone or in parallel with other instruments as an outcome measure in clinical trials of 18 systemic drugs while 22 studies have used it in 14 different topical drug trials. The DLQI has also been used in 27 multinational studies.

CONCLUSIONS

During the last 14 years there has been a gradual increase in the international use of the DLQI. The brevity and simplicity of use of the DLQI has resulted in its popularity both in clinical practice and in research. However, there are various issues in particular regarding its unidimensionality, differential item functioning, and minimal clinically important difference, which require further research. This article should facilitate the work of potential users of the DLQI by providing a readily available source of references for different aspects of the DLQI.

Quality of life in patients with psoriasis and psoriasis arthritis with a special focus on stigmatization experience

Negative impact of psoriasis and psoriasis arthritis on quality of life is a central consequence of these diseases. Feelings of stigmatization might, for example, already emerge with only small patches of skin being affected. Empirical data indicate that treating dermatologists should address possible negative effects elicited by problematic encounters with the public and in sexual relationships even if the severity of the disease is low, because lesions on invisible parts of the body can already cause serious adverse impairment. Such psychosocial consequences can be reduced by attending a self-help organization and by taking part in an interdisciplinary patient education program led by dermatologists.

Construct Validity of the Questionnaire on Experience with Skin Complaints (Short Form)

Abstract. Introduction: Feelings of stigmatization can strongly influence quality of life in individuals with chronic skin diseases. The Short-Form of the Questionnaire on Experience with Skin Complaints (SF-QES) differentiates four factors of stigmatization: self-esteem and retreat, experienced refusal, concealment, and composure. The current study aimed to investigate the construct validity of the SF-QES. Method: The analysis was based on the complete SF-QES records of a clinical psoriasis trial, which yielded 1,005 records at baseline, 1,010 records at the end of therapy, and 885 and 827 records, respectively, at two follow-ups. Factor analyses and corresponding structural equation models (SEMs) using robust maximum likelihood estimation (RML) were applied. Additionally, the responsiveness of the scales to judgments of treatment success and two different interventions were compared. Results: The factor analyses provided results that widely agreed with the supposed four factors. SEM, however, showed moderately insufficient fit for this model, but supported five factors and the discrimination between affected self-esteem and retreat. The retreat scale was clearly most responsive to treatment success and intervention type. Conclusion: The construct validity of the SF-QES was largely supported, but the factor retreat should be separated from affected self-esteem and is most sensitive to physical intervention.

Psoriasisschulung für erwachsene Patienten nach den Regeln der Arbeitsgemeinschaft Dermatologische Prävention

BACKGROUND

Psoriasis vulgaris is a chronic inflammatory skin disease with a substantial impairment of quality of life. Interdisciplinary outpatient educational programs are an innovative supplementary therapy form for the management of this disorder.

SUBJECTS AND METHODS

The Task Force on Dermatological Prevention developed a concept for outpatient instruction of psoriasis patients. Five 2-hour classes by dermatologists, psychotherapists/psychologists and dieticians focus on central topics relevant for the patients and the management of the disease.

RESULTS

The results presented are based on own experiences with this educational program. The interdisciplinary program is accepted very well and seen as helpful by the concerned. A structure analysis of the effects in a greater number of cases is a current goal. In some areas, health insurance companies are paying for the classes.

CONCLUSION

The educational program for the management of psoriasis vulgaris according to the rules of the Task Force on Dermatological Prevention is a supplement of the treatment of patients with this chronic skin disease. Broader implementation in Germany is desirable.

Interdisziplinäre Psoriasisschulung in Blockform für erwachsene Patienten

BACKGROUND

The aim of our pilot study was to evaluate effects of an interdisciplinary training program for adult psoriasis patients after six months follow-up.

SUBJECTS AND METHODS

Eleven patients with psoriasis participated in an interdisciplinary training program over a weekend taught by dermatologists, psychologists/psychiatrists, and dieticians. Six months follow-up was performed with a questionnaire.

RESULTS

The knowledge acquired improved the cooperation with the treating dermatologist (7 of 11), the patients' ability to cope with their disease (11 of 11), and their ability to improving their health status (8 of 11). Their general well-being was increased (9 of 11) and they could better care for their skin disease because they better understood the need for care (9 of 11), and could better judge the best approach for various levels of disease activity (8 of 11).

CONCLUSION

These data show early benefits and suggest such a longer lasting effect of this type of psoriasis training and prevention program. Further studies with larger samples and control parameters will have to examine if these results can be confirmed.

Quality of life in patients with psoriasis

Psoriasis is one of the prevalent skin conditions in the United States. This chronic condition has a significant negative impact on patients' quality of life. Psoriasis has been linked to the depression and suicidal tendencies in the patients. The costs associated with decrements in quality of life, lost productivity, and work absenteeism may be enormous, increasing overall costs associated with the disease management. This review attempts to outline different quality of life measures available for psoriasis and describes their use in studies examining patient reported outcomes associated with pharmacological interventions for psoriasis. Factors associated with quality of life in psoriasis patients are described. It further describes physician's role in the psoriasis management to improve patients' overall well-being.

[The international classification of functioning, disability and health (ICF) in dermatological rehabilitation: conception, application, perspective]

Medical rehabilitation represents the interdisciplinary management of a person's functional health. This term implies concepts of functioning, disability and health and represents the core notion of the international classification of functioning, disability and health (ICF). Four components -- anatomic structure, body functions, activities and participation, environmental factors and personal factors -- make the ICF applicable from a biological, individual and social perspective. At present the ICF is used as a system of classification, a research tool and as a theoretical basis in rehabilitation medicine. Its clinical application will depend on the improvement of its practicability and compatibility with currently used tools in dermatologic rehabilitation. ICF offers the opportunity to define, weight and classify diseases of the skin and their psychosocial consequences.

Psychosoziale Folgen der Psoriasis—eine empirische Studie über die Krankheitslast bei 3753 Betroffenen

BACKGROUND AND OBJECTIVE

The aim of this study was to determine the psychosocial consequences of psoriasis in a large sample in Germany.

PATIENTS AND METHODS

A questionnaire including the Psoriasis Disability Index (PDI) circulated by the German Psoriasis Alliance was answered by 3753 members representing a return rate of 42.3%. Psoriasis was graded-at the time of the examination-with less than 3% of the body surface affected as "mild", between 3 and 10% as "moderate," and more than 10% as "severe."

RESULTS

The general impact of the illness on everyday life was "mild" in about 27%, "problematic" in about 45%, and "severe" in about 25% of the respondents. About 50% of the participants in the study had, concerning the skin, "mild" (PDI=9), about 35% "moderate" (PDI=14), and about 15% "severe" psoriasis (PDI=19). The differences of the PDI values are significant (ANOVA: p<0.001).

CONCLUSIONS

This investigation confirms the enormous burden caused by the skin disease in the form of impairment and stigmatization, depending on the somatic severity, even when the current affection is rather mild. In connection with psychosocial consequences, future study should also focus on the disease burden of psoriasis.

Comparative study of the impact of chronic urticaria, psoriasis and atopic dermatitis on the quality of life

BACKGROUND

A better management of chronic skin disorders (CSDs) requires a knowledge of their impact from the patient's point of view.

OBJECTIVES

To determine which aspects of the patient's life are mainly impaired in the different CSDs, and provide comparative references to estimate better the real impact of the different CSDs.

PATIENTS AND METHODS

A prospective cross-sectional and matched study of 1356 adult outpatients to compare the health-related quality of life (HRQL) profile in chronic urticaria (466 CU), psoriasis (464 PSO) and atopic dermatitis (426 AD), using the VQ-Dermato, a multidimensional instrument in French validated for CSDs.

RESULTS

After adjustment for confounders, HRQL dimensions were differently affected in the three CSDs. The 'physical discomfort' dimension was more degraded in AD and CU than in PSO (P < 0.001), and 'leisure activities' more in PSO than in CU (P < 0.001). 'Self-perception' and 'treatment-induced restrictions' dimensions were much less affected in CU than in PSO and AD (P < 0.001). In PSO, the 'daily living activities' dimension was much less impaired than in CU and AD (P < 0.001). No aspect of HRQL was really spared in AD.

CONCLUSIONS

The comparison shows that CU, PSO and AD are characterized by completely different qualitative profiles of impact on HRQL, which are influenced by their clinical characteristics and usual treatment options. It underlines the severe impairment of CU which is often underestimated.

Stigmatisierung

Stigmatization is associated with considerable psychosocial impairment. Patients with chronic skin disease are especially prone to stigmatization and reduced quality of life. In contrast, patients with self-produced cutaneous artifacts receive an emotional response from family members and doctors. Stigmatization of a religious nature is always difficult for non-participants to understand. We focus on the suffering of the patient, using the example of a historical person, Saint Rita of Cascia, who bore a stigma on her forehead. We discuss why suffering is presented in this manner, and how salvation can be the positive effect of suffering.