Development of the PSORIQoL, a psoriasis-specific measure of quality of life designed for use in clinical practice and trials

The mind-skin connection: A narrative review exploring the link between inflammatory skin diseases and psychological stress

Inflammatory skin diseases are known to negatively impact patient psychology, with individuals experiencing higher rates of stress and subsequent diminished quality of life, as well as mental health issues including anxiety and depression. Moreover, increased psychological stress has been found to exacerbate existing inflammatory skin diseases. The association between inflammatory skin diseases and psychological stress is a timely topic, and a framework to better understand the relationship between the two that integrates available literature is needed. In this narrative review article, we discuss potential neurobiological mechanisms behind psychological stress due to inflammatory skin diseases, focusing mainly on proinflammatory cytokines in the circulating system (the brain-gut-skin communications) and the default mode network in the brain. We also discuss potential descending pathways from the brain that lead to aggravation of inflammatory skin diseases due to psychological stress, including the central and peripheral hypothalamic-pituitary-adrenal axes, peripheral nerves and the skin barrier function.

Patient-Reported Outcome Measures for Health-Related Quality of Life in Patients With Psoriasis: A Systematic Review

Importance

Multiple patient-reported outcome measures (PROMs) for health-related quality of life (HRQL) exist for patients with psoriasis. Evidence for the content validity and other measurement properties of these PROMs is critical to determine which HRQL PROMs could be recommended for use.

Objective

To systematically review the validity of HRQL-focused PROMs used in patients with psoriasis.

Evidence Review

Using PubMed and Embase, full-text articles published in English or Spanish on development or validation studies for psoriasis-specific, dermatology-specific, or generic HRQL PROMs were included. Development studies included original development studies, even if not studied in psoriasis patients per Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) recommendations. If a study included multiple diagnoses, more than 50% of patients had to have psoriasis or psoriasis-specific subgroup analyses available. Data extraction and analysis followed the COSMIN guidelines. Two independent reviewers extracted and analyzed the data, including PROM characteristics, quality of measurement properties (structural validity, internal consistency, cross-cultural validity, reliability, measurement error, criterion validity, construct validity, and responsiveness), and level of evidence. PROMs were classified into 3 levels of recommendations: (1) PROM recommended for use; (2) PROM requires further validation; and (3) PROM not recommended for use.

Findings

Overall, 97 articles were identified for extraction. This included 19 psoriasis-specific, 8 skin-specific, and 6 generic PROMs. According to COSMIN standards, most measures identified received a B recommendation for use, indicating their potential but requiring further validation. Only the Rasch reduced version of the Impact of Psoriasis Questionnaire (IPSO-11 Rasch) received an A recommendation for use given that it had sufficient content validity, structural validity, and internal consistency.

Conclusions and Relevance

This study identified a significant lack of information concerning the quality of HRQL measures in psoriasis. This gap in knowledge can be attributed to the fact that traditional measures were developed using validation criteria that differ from the current standards in use. Consequently, additional validation studies in accordance with contemporary standards will be useful in aiding researchers and clinicians in determining the most suitable measure for assessing HRQL in patients with psoriasis.

Implementing well-being in the management of psoriasis: An expert recommendation

Psoriasis causes detriment in a person's physical, mental and social health which impairs their quality of life (QoL). However, the current psoriasis management may not adequately address all relevant health domains. Since the goal of healthcare is to restore or maintain health, health outcomes should include all areas of the patient's overall health. Life satisfaction, QoL and patient well-being are essential to a comprehensive approach to the disease. With the inclusion of more people-centred policies, care of patients with psoriasis should evolve towards a holistic and integrated assessment of the disease impact, including subjective measures of well-being in order to encompass all aspects of health. The main objective of this expert review is to give the concept of well-being a place as an entity within the holistic therapeutic approach for patients with psoriasis. Identifying and defining common goals beyond the skin with the patient and testing them throughout the course of treatment will benefit and enhance treatment success. We propose a series of recommendations for application in clinical practice, providing tangible clinical guidance for implementing well-being in the management of psoriasis. Among the recommendations are the need to initially listen to the patient, to know their level of empowerment or what they want to achieve, their preferences in decision making, the evaluation of not only the physical but also the emotional impact of the disease (well-being), the definition of the aspects that can generate a cumulative deterioration of the disease throughout life, and a continuous assessment of the patient's preferences with the opinion of the expert clinician and the integration of the knowledge of external clinical evidence.

Development and validation of a psoriasis treatment acceptability measure through group concept mapping

BACKGROUND

Psoriasis is a common autoimmune dermatologic condition which has a pronounced negative impact on patient quality of life and disease burden. Currently, there are a number of treatments available for psoriasis, with differences in efficacy, mechanism of action, mode of administration, adverse effects, and tolerability. However, a reliable, validated patient-reported instrument to address patient expectations and of psoriasis treatment has not been developed. This project was undertaken with the aim of developing a fit-for-purpose self-reported instrument to inform patient expectations and preferences of psoriasis treatments.

METHODS

Two studies, both utilizing qualitative and quantitative methods, were conducted in patients within the entire spectrum of psoriasis severity. In Study 1, a group concept mapping (GCM) exercise was conducted with dermatologists and moderate-to-severe psoriasis patients to identify concepts important in the treatment of psoriasis. In Study 2, a preliminary Treatment Acceptability Questionnaire (TAQ) was developed using GCM-derived concepts from Studies 1 and 2, followed by cognitive debriefing (CD) telephone interviews of the preliminary TAQ. In Study 2, another GCM exercise was conducted with mild and newly diagnosed psoriasis patients. Psychometric analyses were performed on the TAQ to evaluate validity and reliability.

RESULTS

The Study 1 GCM exercise generated 43 concepts from moderate-to-severe psoriasis patients (n = 20) and dermatologists (n = 10). In Study 2, 37 GCM concepts were generated from mild and newly diagnosed psoriasis patients (n = 20). From the 2 GCM exercises, 28 concepts were selected to form the preliminary TAQ; CD interviews indicated strong understanding and relevance of TAQ items among patients with disease ranging from mild to severe. The final TAQ consisted of 20 items; psychometric analysis demonstrated strong validity and reliability of the TAQ.

CONCLUSIONS

The TAQ is a novel psychometrically validated patient-reported instrument to inform healthcare providers of patients' expectations of and preferences for treatment of their psoriasis and can help in shared decision making between patients and physicians.

Development and validation of the psoriasis scale among the system of quality of life instruments for chronic diseases QLICD-PS (V2.0)

Background and purpose

Psoriasis (PS) is difficult to cure with a high incidence. Therefore, the quality of life (QOL) of people with Psoriasis has caused widespread concern. Universal scales respond poorly to subtle changes caused by specific diseases, which makes it challenging to fully understand the impact of QOL in patients with psoriasis. In view of the deficiencies of the universal scale and the lack of a specific scale suitable for Chinese cultural background, this study aims to develop the psoriasis scale among the system of QOL instruments for chronic diseases QLICD-PS (V2.0).

Methods

The scale QLICD-PS (V2.0) was developed based on the procedural decision-making approach and the experience of establishing scales at home and abroad. 122 patients with psoriasis were participated in measuring QOL 3 times before and after treatments. The reliability was assessed by test–retest reliability (Pearson’s correlation coefficients) and also internal consistency (Cronbach’s alpha coefficients). Qualitative analysis was adopted to evaluate content validity; item-domain correlation analysis, multi-dimensional scaling analysis, and factor analysis were adopted to evaluate the construct validity; the SF-36 scale was used as the criterion to evaluate the criterion-related validity due to lack of gold standard. Paired t tests were performed to evaluate the responsiveness on each domain/facet as well as the total of the scale, with Standardized Response Mean (SRM) being calculated.

Results

The QLICD-PS was composed of the general module including 3 domains (28 items) and the psoriasis specific module (13 items). The Cronbach's α of the specific module, the general module and the total scale of the QLICD-PS was 0.78, 0.87 and 0.74 respectively, the split-half reliability of the specific module, the general module and the total scale was 0.81, 0.91 and 0.81, respectively, both indicating high reliability. Correlation and factor analysis confirmed good construct validity and criterion-related validity. After treatments, the score changes in the total scale were statistically significant with SRM being 0.5, showing moderate responsiveness.

Conclusion

As the first psoriasis-specific QOL scale developed by the modular approach in Chinese, the QLICD-PS showed good reliability, validity and responsiveness, and could be used to measure the QOL of Patients with psoriasis specifically and sufficiently.

Nail Psoriasis and Quality-of-Life Measurement in Clinical Trials: Call for the Use of Nail-Specific Instruments

Nail involvement is frequent in people with psoriasis. It can considerably impair health-related quality of life (HRQoL) beyond the impairments due to other psoriasis symptoms, for example, because patients feel ashamed of visible nail defects or because of the functional impairment in manual activities and walking. In clinical trials on nail psoriasis, it is therefore crucial to assess whether the treatment reduces HRQoL impairments that are specific to nail psoriasis. For this purpose, two validated patient questionnaires are available, the Nail Psoriasis Quality of Life Scale (NPQ10) and the Nail Assessment in Psoriasis and Psoriatic Arthritis-Quality of Life (NAPPA-QOL). The ten-item NPQ10 has the advantage of being short and thus quick to administer. The 20-item NAPPA-QOL, in contrast, assesses the different dimensions of HRQoL which is considered a multi-dimensional construct. Yet most randomized controlled trials on nail psoriasis do not evaluate HRQoL improvement. If they do, a number of different instruments are used, most of which are not nail specific. This makes comparison of trial outcomes difficult. Harmonizing the measurement of HRQoL in future clinical trials on nail psoriasis would improve comparability across studies and would also enhance the reliability of meta-analyses.

Fixed-dose combination calcipotriol/betamethasone dipropionate foam provides a rapid onset of action, effective itch relief and improves patient quality of life

The physical symptoms of psoriasis vulgaris (chronic plaque psoriasis), such as itch and itch‐related sleep loss, and the psychological impact of visible plaques on the body, all contribute to significantly reduced health‐related quality of life (HRQoL) in patients with psoriasis. In fact, the deterioration of HRQoL in patients with psoriasis is similar to patients with other chronic conditions, such as cancer and cardiovascular diseases. Rapid and effective improvements in HRQoL and itch‐related outcomes would therefore be highly valued by patients and may even improve adherence to treatment. In this article, we summarise previously published data assessing the impact of fixed‐dose combination calcipotriol 50 µg/g plus betamethasone dipropionate 0.5 mg/g cutaneous foam (Cal/BD foam) on itch relief, quality of sleep, onset of action and HRQoL. Findings across multiple analyses indicate that Cal/BD foam provides significant improvements in itch, itch‐related sleep loss and HRQoL compared with vehicle foam or Cal/BD gel comparators. Additionally, the benefits of Cal/BD foam were recorded earlier than these comparators, often within 1 week of treatment, indicating a rapid onset of action. With the published data to hand, it is clear that Cal/BD foam provides significant improvements in the outcomes that matter most to patients and should be considered an effective topical treatment for psoriasis.

Video abstract

Fundamental Measurement: The Need Fulfilment Quality of Life (N-QOL) Measure

The quality adjusted life year (QALY) has serious problems related to its failure to adhere to measurement theory. If a QALY is to be meaningful, the utility score that translates time spent to an equivalent time spent in so-called perfect health must have ratio properties (i.e., it must support multiplication). Multiattribute utility scores (e.g. those generated by the EQ-5D-5L) fail to meet this standard. The multiattribute instruments produce ordinal scores that lack a true zero and they generate negative values. The manifest deficiencies of multiattribute utility instruments render them unfit, not only as a measure of therapy response but also in generating QALY claims. After 30 years of belief in their use, utilities and QALYs are clearly analytical dead ends.

The purpose of this commentary is to demonstrate a coherent way forward in health technology assessment by focusing, not on clinical attributes as surrogates for quality of life, but on measures that are based on a conceptual model describing patient value in terms of need-fulfilment. Building on an extensive, yet often overlooked literature, need-based measures that fit Rasch Measurement Theory criteria are converted from ordinal scores to interval scores to evaluate response to therapy. These measures meet the requirements of single attribute fundamental measurement which is the standard in the physical sciences. It is proposed that a translation from a Rasch interval scale (defined by logits) can be transformed to a bounded ratio scale. Need based Quality of Life (N-QOL) scales bounded by 0 (where no needs are fulfilled) to 1 (where all needs are fulfilled) form such scales. The N-QOL supports the full range of arithmetic operations. Multiattribute utilities and mathematically invalid QALYs can be put to one side as unfortunate historical curiosities in favor of a disease or target population specific N-QOL scale. Such a scale has the required properties to evaluate disease specific response to therapy This can also support N-QOL adjusted life years with a need- fulfillment life year (NALY) metric with ratio properties.

Quality of life of patients with psoriasis

OBJECTIVE

The two main aims of our study were to assess the quality of life (QOL) of patients with moderate or severe psoriasis treated by Goeckerman therapy and to compare QOL of our patients on the date of admission and 1 month after their discharge.

METHODS

We performed a prospective study on 51 patients treated for chronic plaque psoriasis by Goeckerman regimen (GR). The psoriasis area involvement and severity was measured using the Psoriasis Area and Severity Index (PASI). Patients' health-related QOL was evaluated using Psoriasis Disability Index (PDI).

RESULTS

In our study we demonstrated that the QOL of this sample of 51 patients with severe forms of psoriasis was relatively good; an average PDI value on the day of admission was 9.02, which represents a small effect on patient's QOL. We did not find any significant differences in QOL between younger and older respondents or between men and women. Despite good treatment efficiency, we did not find improvement in QOL 1 month after discharge.

CONCLUSIONS

The QOL of our patients was relatively good. This could be explained by the fact that our patients have been suffering from psoriasis for many years and have probably adapted to their disease. QOL of our patients was not directly dependent on the extent and intensity of skin changes. Further studies on the connection between psoriasis therapy and patients' QOL are still highly needed.

Treatment Goals in Psoriasis: Which Outcomes Matter Most?

Psoriasis is a chronic immune-mediated inflammatory disease that predominantly affects the skin and joints. Its detrimental effects on the physical, psychosocial, and emotional well-being of patients leads to a significant reduction in quality of life (QoL). The goals of treatment focus on decreasing disease severity and improving QoL for patients; accomplishing these goals requires physicians to understand both the full impact of the disease on a patient's life and the outcomes that matter most to patients. The use of outcome measures, both physician- and patient-reported, can assist clinicians in evaluating the disease burden and its effect on QoL and in identifying patient preferences for treatment, ultimately enhancing quality of care. However, current outcome measures have many limitations and do not adequately capture patients' needs and priorities. Nevertheless, physicians treating patients with psoriasis are encouraged to utilize these instruments while remaining cognizant of each of their limitations. As there is no consensus on an outcome measure that fully encompasses the complexities of psoriasis and its impact on patients, instruments that are appropriate and applicable to dermatologists and their patients should be developed.

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

Background

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

Objectives

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

Methods

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

Results

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

Conclusions

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

What's already known about this topic?

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

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

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

What does this study add?

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

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

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

Measurement of patient-reported outcomes. 1: The search for the Holy Grail

Patient-reported outcome measures (PROMs) are used to collect information directly from patients. They may cover several different types of outcomes ranging from symptoms, functioning, utility, satisfaction, through to quality-of-life (QoL). They generally consist of self-completed questionnaires that can be administered by means of hard copies or in a range of electronic formats. PROMs vary considerably in terms of the constructs they assess, the care with which they are developed, and their scientific quality. However, none of the PROMs available approach the quality of measurement achieved by measures/instruments used in physics. PROs are examples of latent variables. These are not directly observable, but can be inferred from, for example, responses to a questionnaire. The only measure of a latent variable that approaches the quality of measurement achieved by the physical sciences is the Lexile Framework for Reading. This framework is based on a construct theory that grew out of an analysis of several available reading measures. A specification equation was generated that was able to link the construct theory to scores obtained with the Lexile measure. A fundamental requirement of this quality of measurement is that the data collected with the model fit Rasch Measurement Theory (RMT). It is argued that PROM developers should aspire to match this level of measurement sophistication if their instruments are to provide valid insights into the impacts of disease and its treatment.

Acupuncture combined with herbal medicine versus herbal medicine alone for plaque psoriasis: a systematic review protocol

Background

Psoriasis is a condition with a multifactorial etiopathogenesis worldwide, and plaque psoriasis, which is characterized by redness, thickness, and scaling, is the most common kind. Individuals living with psoriasis show low levels of life quality, and having fewer or less extensive lesions may improve spiritual and mental health. Therefore, our objective is to explore the effectiveness of acupuncture combined with herbal medicine for plaque psoriasis and to compare acupuncture combined with herbal medicine with herbal medicine alone.

Methods

Databases including PubMed, MEDLINE, the Cochrane Library, Excerpta Medica (EMBASE), the Chinese Biomedical Literature Database (CBM), the China National Knowledge Infrastructure Database (CNKI), the Wanfang database and the Chinese Scientific Journal Database (VIP database) will be searched from inception to March 2018. We will employ hand searches, and grey literature will also be obtained. Only randomized controlled trials evaluating acupuncture combined with herbal medicine to treat plaque psoriasis in adults will be assessed. The Psoriasis Area and Severity Index score (PASI score), the itching index, the life quality scores, and the anxiety index will be the outcome measures. Two independent reviewers will select the articles included, assess the risk of bias and extract data according to the inclusion criteria. A third reviewer will resolve disagreements. The purpose of this study will be to identify the effect of acupuncture combined with herbal medicine on the lesions (PASI score), symptoms (itching index, life quality scores) and mental status (anxiety index) of the patients.

Discussion

The meta-analysis will retrospectively examine current evidence regarding the effectiveness of the practice of acupuncture combined with herbal medicine to treat plaque psoriasis. This study may reveal, for the first time, an adjuvant therapy for psoriasis.

Trial registration

As the study is a systematic review protocol, trial registration will not be necessary. An article containing the results will be published in a peer-reviewed journal and disseminated through scientific conferences.

A qualitative study of the impact of plexiform neurofibromas on need fulfilment in adults with neurofibromatosis type 1

Objective

To explore the impact of plexiform neurofibromas on the lives of adults with neurofibromatosis type 1.

Background

Neurofibromatosis type 1 is a complex neurogenetic syndrome that affects many aspects of health and functioning. A common manifestation of neurofibromatosis type 1 is plexiform neurofibromas, non-cancerous tumours that can cause disfigurement, pain and neurologic disability. Patient-reported outcome measures used in this condition have addressed symptoms and functional ability but not how the condition affects patients' lives, particularly, their ability to meet their human needs.

Methods

Unstructured qualitative interviews were conducted with adults with neurofibromatosis type 1-associated plexiform neurofibromas in the United Kingdom and United States. Interviewees were encouraged to describe how plexiform neurofibromas affected their ability to meet their needs. Interviews were audio-recorded and transcribed verbatim. The UK and US transcripts were combined and theoretical thematic analysis was conducted.

Results

In all, 42 interviews (United Kingdom = 20, United States = 22) were conducted. Transcripts revealed 696 statements on the impact of plexiform neurofibromas on need fulfilment. Five major themes emerged: appearance, relationships, independence, role fulfilment and pleasure.

Conclusion

Neurofibromatosis type 1-associated plexiform neurofibromas have a major effect on individuals' ability to meet their needs. An understanding of need fulfilment will complement information generated from traditional patient-reported outcome measures, particularly in a multi-faceted syndrome such as neurofibromatosis type 1.

Methotrexate for psoriatic arthritis

BACKGROUND

Psoriatic arthritis is an inflammatory disease associated with joint damage, impaired function, pain, and reduced quality of life. Methotrexate is a disease-modifying anti-rheumatic drug (DMARD) commonly prescribed to alleviate symptoms, attenuate disease activity, and prevent progression of disease.

OBJECTIVES

To assess the benefits and harms of methotrexate for psoriatic arthritis in adults.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, the WHO International Clinical Trials Registry Platform, and www.clinicaltrials.gov for relevant records. We searched all databases from inception to 29 January 2018. We handsearched included articles for additional records and contacted study authors for additional unpublished data. We applied no language restrictions.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) and quasi-RCTs that compared methotrexate versus placebo, or versus another DMARD, for adults with psoriatic arthritis. We reported on the following major outcomes: disease response (measured by psoriatic arthritis response criteria (PsARC)), function (measured by the Health Assessment Questionnaire for Rheumatoid Arthritis (HAQ)), health-related quality of life, disease activity (measured by disease activity score (28 joints) with erythrocyte sedimentation rate (DAS28-ESR)), radiographic progression, serious adverse events, and withdrawals due to adverse events.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed search results, assessed risk of bias, extracted trial data, and assessed the quality of evidence using the GRADE approach. We undertook meta-analysis only when this was meaningful.

MAIN RESULTS

We included in this review eight RCTs conducted in an outpatient setting, in Italy, the United Kingdom, the United States of America, China, Russia, and Bangladesh. Five studies compared methotrexate versus placebo, and four studies compared methotrexate versus other DMARDs. The average age of participants varied across studies (26 to 52 years), as did the average duration of psoriatic arthritis (one to nine years). Doses of methotrexate varied from 7.5 mg to 25 mg orally per week, but most studies administered approximately 15 mg or less orally per week. Risk of bias was generally unclear or high across most domains for all studies. We considered only one study to have low risk of selection and detection bias. The main study informing results of the primary comparison (methotrexate vs placebo up to six months) was at low risk of bias for all domains except attrition bias and reporting bias.We restricted reporting of results to the comparison of methotrexate versus placebo for up to six months. Low-quality evidence (downgraded due to bias and imprecision) from a single study (221 participants; methotrexate dose 15 mg orally or less per week) informed results for disease response, function, and disease activity. Disease response, measured by the proportion who responded to treatment according to PsARC (response indicates improvement), was 41/109 in the methotrexate group and 24/112 in the placebo group (risk ratio (RR) 1.76, 95% confidence interval (CI) 1.14 to 2.70). This equates to an absolute difference of 16% more responders with methotrexate (4% more to 28% more), and a number needed to treat for an additional beneficial outcome (NNTB) of 6 (95% CI 5 to 25). Mean function, measured by the HAQ (scale 0 to 3; 0 meaning no functional impairment; minimum clinically important difference 0.22), was 1.0 points with placebo and 0.3 points better (95% 0.51 better to 0.09 better) with methotrexate; absolute improvement was 10% (3% better to 17% better), and relative improvement 30% (9% better to 51% better). Mean disease activity as measured by the DAS28-ESR (scale of 0 to 10; lower score means lower disease activity; minimum clinically important difference unknown) was 3.8 points in the methotrexate group and 4.06 points in the placebo group; mean difference was -0.26 points (95% CI -0.65 to 0.13); absolute improvement was 3% (7% better to 1% worse), and relative improvement 6% (16% better to 3% worse).Low-quality evidence (downgraded due to risk of bias and imprecision) from three studies (n = 293) informed our results for serious adverse events and withdrawals due to adverse events. Due to low event rates, we are uncertain if methotrexate results show increased risk of serious adverse events or withdrawals due to adverse events compared to placebo. Results show 1/141 serious adverse events in the methotrexate group and 4/152 in the placebo group: RR 0.26 (95% CI 0.03 to 2.26); absolute difference was 2% fewer events with methotrexate (5% fewer to 1% more). In all, 9/141 withdrawals in the methotrexate group were due to adverse events and 7/152 in the placebo group: RR 1.32 (95% CI 0.51 to 3.42); absolute difference was 1% more withdrawals (4% fewer to 6% more).One study measured health-related quality of life but did not report these results. No study measured radiographic progression.

AUTHORS' CONCLUSIONS

Low-quality evidence suggests that low-dose (15 mg or less) oral methotrexate might be slightly more effective than placebo when taken for six months; however we are uncertain if it is more harmful. Effects of methotrexate on health-related quality of life, radiographic progression, enthesitis, dactylitis, and fatigue; its benefits beyond six months; and effects of higher-dose methotrexate have not been measured or reported in a randomised placebo-controlled trial.

Qualitative Methods Used to Generate Questionnaire Items: A Systematic Review

A systematic review of articles using qualitative methods to generate questionnaire items identified in MEDLINE and PsycINFO from 2000 to 2014 was carried out. Articles were analyzed for (a) year of publication and journal domain, (b) qualitative data collection methods, (c) method of data content analysis, (d) professional experts' input in item generation, and (e) debriefing of the newly developed items. In total, 371 articles were included and results showed (a) an acceleration of published articles, (b) individual interviews and focus groups were common ways of generating items and no emergent approach was identified, (c) the content analysis was usually not described (43% of articles), (d) experts were involved in eliciting concepts in less than a third of articles, (e) 61% of articles involved a step of further submission of newly developed items to the population of interest. This review showed an insufficient reporting of qualitative methods used to generate new questionnaires despite previous recommendations.

Patient value: its nature, measurement, and role in real world evidence studies and outcomes-based reimbursement

The assessment of "patient value" is fundamental to clinical trials, real world evidence studies, and outcomes-based reimbursement schemes. Measures of health-related quality-of-life (HRQoL) are widely used in health research. Such measures are effective in determining the presence or absence of symptoms and functional ability. However, HRQoL measures were not intended, nor designed, to determine the value to patients of alternative health states. Functions have no intrinsic value-they are a means to fulfil human needs. However, needs can be met in a variety of ways, for example by adopting different functions or by the provision of social services. It is possible to analyze all functions in terms of the needs they satisfy. A needs model has been applied in health research since the 1990s. It is concerned with the extent to which human needs are fulfilled in the presence of disease and its treatment. It is argued that this is the major concern of the patient. Needs-based measures are patient-centric and produce a valid unidimensional index of outcome. Consequently, they provide a direct means of measuring patient value. This approach provides the possibility of evaluating health services in terms of the value they provide to consumers and payers. It also has a role to play in real-world evidence studies and outcomes-based reimbursement. It is recommended that greater attention is given in future to the development of patient-reported outcome measures that provide direct assessments of patient value.

The Pathophysiological Mechanisms and the Quest for Biomarkers in Psoriasis, a Stress-Related Skin Disease

Psoriasis is a physically, emotionally, and socially invalidating multifactorial disorder, with a significant impact on the patients' quality of life. Stress is one of the leading triggers for psoriasis and has been associated with disease onset and subsequent flare-ups, while the flare-ups by themselves often lead to psychological discomfort. The treatment of psoriasis is individualized, depending on the patients' measurable severity of illness, as well as the impact the skin condition has on patients' quality of life, as assessed by standardized questionnaires. The clinical scales used nowadays for measuring the severity of psoriasis are characterized by low reproducibility and high variability between examiners. Hence, there is a real need to identify objectively measurable biomarkers to standardize the assessment of the severity of psoriasis. We aim to review the pathophysiological mechanisms involved in psoriasis, focusing on the most critical advances in psoriasis biomarker discovery, pointing out those biomarkers which have also been studied in other stress-related conditions, thus emphasizing the relationship between psoriasis and stress.

The impact of biologic agents on health-related quality of life outcomes in patients with psoriasis

INTRODUCTION

Psoriasis is a common, immune-mediated skin disease often associated with significant physical and psychosocial impairment. Antipsoriatic biologic agents offer patients unparalleled treatment potential in regard to greater skin clearance and overall improved quality of life. Evaluation of the therapeutic efficacy of biologic agents on the full psoriasis disease burden must account for their impact on both physical symptoms, as well as patient-reported, health-related quality of life (HRQoL) measurements. Areas covered: Results from numerous clinical trials demonstrate the significant clinical efficacy of biological agents targeting tumor necrosis factor-α (TNF-α) and the interleukin (IL)-12/23 and IL-17 immune pathways. However, relatively limited data is available evaluating their full effect on quality of life outcomes. This review will discuss the most relevant and up-to-date clinical data on HRQoL measurements related to treatment with these aforementioned biologic agents. Expert commentary: Patient-reported outcomes (i.e. Dermatology Life Quality Index) are being used with increasing frequency in clinical trials, and provide valuable information on the impact of psoriasis on numerous aspects of day-to-day living. These outcomes must also be incorporated in clinical practice, in addition to physical assessment of disease severity, treatment decisions, and therapeutic response in the psoriasis patient population.

Quality of life among dermatology patients: a systematic review of investigations using qualitative methods

INTRODUCTION

Quality of life may be assessed using quantitative or qualitative methods. Quantitative methods are commonly used in research settings; however, they may fail to capture the full range of patient experiences and impact on quality of life. Qualitative methods may be used to address this limitation. In this systematic review, we aim to synthesize data from articles utilizing qualitative methods to assess quality of life in dermatology patients.

EVIDENCE ACQUISITION

We performed a systematic review search using the MEDLINE, EMBASE, and SCOPUS databases. The search was conducted using the following search criteria: ("Dermatology" [MeSH]) AND ("Quality of Life" [MeSH]), AND ("Qualitative Research" [MeSH]), searching literature spanning from January 1, 1946 to October 5, 2016.

EVIDENCE SYNTHESIS

The systematic review of 15 articles included 533 dermatology patients. Patients expressed frustration over the unpredictability of disease symptoms and having to compensate for the subsequent limitations by altering their daily routines. Patients also reported profound helplessness due to chronic skin disease and social isolation in an effort to hide their disease. Patients noted the patient-provider relationship as a source of support and information exchange, with the goal to form easy to use treatment plans that met both physician and patient expectations.

CONCLUSIONS

Qualitative assessment of patient quality of life can provide new insights into the patient experience and the impact of their skin disease. Qualitative methodology may capture meaningful information that may be overlooked by quantitative methods, and it should be included in quality of life research.

General measures and quality of life issues in psoriasis

Psoriasis generally does not affect survival but has significant detrimental effect on quality of life (QOL), which may be comparable to that of ischemic heart disease, diabetes, depression, and cancer. The foremost important thing in the management of psoriasis is counseling of the patient. The clinician needs to be empathetic and spend adequate time with the patient and educating the patient about psoriasis. Clinicians should make it clear to the patient that the primary goal of treatment is control of the disease rather than cure. Eating a balanced and low glycemic diet could be an important adjuvant factor in the prevention and treatment of moderate nonpustular psoriasis. Obese people are more likely to have severe psoriasis and psoriatic arthritis than people with an average body mass index. Dietary supplementation with oily fish, rich in n-3 fatty acids, in psoriasis had shown mixed results in trials. Promising results have been documented for parenteral application of n-3 fatty acid, but not with oral supplementation. Increased smoking or alcohol abuse increases the risk of developing psoriasis and may influence disease severity, and hence must be avoided. Soaking in warm water with bath oil can be done in extensive psoriasis for hydration and emollient effect, and bland soaps or soap substitutes should be used; antiseptics should be avoided as they may irritate the skin. Relatively small, localized patches of psoriasis may improve with occlusion, i.e., waterproof adhesive dressings. The use of emollients is an internationally accepted standard adjunctive to the treatment of psoriasis. Dermatology Life Quality Index is a psychometrically sound and responsive measure of psoriasis-specific outcomes and most comprehensively captures the impact of clinical signs and symptoms on patient's well-being.

Peer-relationship-problems account for quality of life impairments in pediatric psoriasis

OBJECTIVE

Most research on HRQoL-impairments in psoriasis has been conducted in adult patients, small pediatric patient samples or samples not representative of the pediatric population at large. We thus aimed to comprehensively describe HRQoL in pediatric psoriasis compared to psoriasis-free children and adolescents, identify domains most commonly affected and analyze its impact on HRQoL while controlling for important other predictors of HRQoL in a representative pediatric sample.

METHODS

The impact of lifetime-prevalence of psoriasis on total and subscale HRQoL was analyzed by complex sample general linear models alone and adjusted for sociodemographic and clinical variables in a population-based sample (n=6518) of children and adolescents aged 11-17.

RESULTS

Total HRQoL and the physical domain were significantly affected by lifetime-psoriasis in univariate analysis. In multivariate analyses, lifetime-psoriasis significantly impacted on total HRQoL and the subscale 'quality of relationships with friends/peers'. Although substantial amounts of variance in HRQoL were explained by mental health, independent effects of lifetime-psoriasis remained after adjustment for this covariate. Total explained variance in total HRQoL was 20%.

CONCLUSION

Our findings suggest psoriasis to be a significant burden as it affects HRQoL even when controlling for mental health. Most of this effect appears to be driven by perceived impairments in the quality of relationship with friends/peers. How this exactly occurs needs to be explored in future research. Meanwhile clinicians need to be more attentive to this effect of psoriasis.

Translation, cross-cultural adaptation and validation of the vitiligo-specific health-related quality of life instrument (VitiQoL) into Brazilian Portuguese

BACKGROUND:

Vitiligo, although asymptomatic, highly compromises patients' quality of life (QoL). Therefore, an adequate evaluation of QoL is essential.

OBJECTIVES:

Translation, cultural adaptation and validation of VitiQol (Vitiligo-specific health-related quality of life instrument) into Brazilian Portuguese.

METHODS:

The study was conducted in two stages; the first stage was the translation and cultural/linguistic adaptation of the instrument; the second stage was the instrument's validation.

RESULTS:

The translated VitiQol showed high internal consistency (Cronbach alpha = 0.944) and high test-retest reliability and intraclass correlation coefficient=0.95 (CI 95% 0.86 - 0.98), p<0.001. There was no statistically significant difference between the means of the first completion of the VitiQoL questionnaire and the retest, p = 0.661. There was a significant correlation between VitiQoL and DLQI (r = 0.776, p <0.001) and also between VitiQoL-PB and subjects' assessment of the severity of their disease (r = 0.702, p <0.001).

CONCLUSIONS:

The impact of vitiligo on the QoL of Brazilian patients can be assessed by a specific questionnaire.

Patient-reported outcome measures in psoriasis: the good, the bad and the missing!

As a long-term condition, psoriasis demands significant personal and professional input for optimal self-management. Low levels of well-being and high levels of psychological distress in patients with psoriasis are associated with reduced resources for self-care. Patient-reported outcome (PRO) measures can be used to assess physical, social and psychological functioning in order to guide treatment. In this article, we systematically reviewed the development and validation of existing PRO measures. PubMed (Medline), PsycINFO and CINAHL were searched systematically using predefined search terms. The search was limited to articles in the English language relating to human subjects. Articles were selected for full review through explicit inclusion/exclusion criteria. PRO measures were critically reviewed in accordance with the published guidelines and theory on the development and validation of PROs. The search identified 967 abstracts; 71 of these articles met the criteria for full review. In these 71 articles, 45 PRO measures were found: 16 were specific to psoriasis, 21 assessed other dermatological conditions and eight were developed for generic nondermatological health conditions. The review revealed several limitations of the existing measures, including: (i) a composite structure assessing multiple, poorly-defined concepts; (ii) a lack of evidence for face and content validity; (iii) a failure to include both patient and clinician perspectives and requirements and (iv) a lack of evidence regarding the feasibility and acceptability for patients and physicians. No single PRO measure with adequate evidence of validity, reliability and sensitivity to change captures patient well-being in psoriasis. A valid, sensitive, specific and acceptable PRO that assesses the full impact of psoriasis on well-being is needed for the comprehensive clinical management of psoriasis.

Development and psychometric validation of the REFlective evaLuation of psoriasis Efficacy of Treatment and Severity (REFLETS) questionnaire: a common measure of plaque-type psoriasis severity and treatment efficacy for patients and clinicians

BACKGROUND

To date, there is no global consensus on the definition of the severity of psoriasis. The REFlective evaLuation of psoriasis Efficacy of Treatment and Severity (REFLETS) questionnaire has recently been developed to provide a better understanding of plaque-type psoriasis severity and treatment efficacy from both patient and clinician perspectives.

OBJECTIVE

This study aimed to develop and psychometrically validate the new REFLETS questionnaire to evaluate patient and clinician perceptions of plaque-type psoriasis severity and treatment efficacy.

METHODS

Two similar versions of the REFLETS questionnaire were developed following a rigorous methodology for clinicians and patients, referring to 'the psoriasis of your patient' or to 'your psoriasis', respectively. An observational, longitudinal, multicentre study was conducted in France with 34 dermatologists and 430 mild to severe plaque-type psoriasis patients to finalize the questionnaire and evaluate its psychometric properties.

RESULTS

Two dimensions were defined--severity and treatment efficacy--with three subdimensions within severity (impact of psoriasis, symptoms and disease course), and two individual items on joint pain. The questionnaire was well accepted by clinicians and patients. Excellent internal consistency (Cronbach's alpha = 0.66-0.98) and test-retest reliability (intraclass correlation coefficients = 0.83-0.94) were demonstrated. REFLETS scores were moderately to highly correlated to Psoriasis Area and Severity Index (r = 0.35-0.70), Skindex-29 (r = 0.46-0.82) and DLQI scores (r = 0.36-0.82). Patients with decreased psoriasis severity and those with increased treatment efficacy, according to patient global evaluations, had lower severity and higher treatment efficacy REFLETS scores, respectively.

CONCLUSION

REFlective evaLuation of psoriasis Efficacy of Treatment and Severity is a promising tool for assessing plaque-type psoriasis severity and treatment efficacy from patient and clinician perspectives. It may help to improve patient and clinician communication in treatment decision making.

Results of the validation study of the Psodisk instrument, and determination of the cut-off scores for varying degrees of impairment

BACKGROUND

The Psodisk is a 10-item visual instrument, aimed at measuring the burden of psoriasis on patients.

OBJECTIVES

To validate the Psodisk in a large sample of patients with psoriasis, and to define categories for the interpretation of the scores.

METHODS

Data were collected in 21 dermatological centres. The Psodisk was administered at baseline (t0), after 2 or 3 days (t1) and about 3 months (t2) after baseline, and data were used to assess validity and reliability of the instrument. The cut-off scores were determined using the perception of the severity of the disease by the patient as anchor point.

RESULTS

The evaluable population consisted of 320 patients at baseline, with a mean Psodisk score of 36.9. The concurrent validity of the instrument was confirmed by the high correlation with Skindex-29 and DLQI. Factor analyses selected a single factor, which alone explained almost 60% of the variance. Cronbach's coefficient alpha was 0.927, suggesting a good reliability. Test-retest reliability was verified by a Pearson's correlation coefficient between the Psodisk scores at baseline and t1 of 0.924. Five categories of disease burden were defined: 1. minimal (<9); 2. mild (9-15); 3. moderate (16-30); 4. marked (31-50); 5. severe (>50).

CONCLUSION

The Psodisk showed good psychometric properties. The definition of the cut-off scores will be useful to evaluate the burden of psoriasis on patients.

The Polish version of Skindex-29: psychometric properties of an instrument to measure quality of life in dermatology

Introduction

Skin conditions have a negative impact on quality of life and it is necessary to quantify this impact. Skindex-29 is a self-report questionnaire developed to measure dermatology-specific quality of life.

Aim

The objective of this study is to adapt this questionnaire to Polish conditions. The adaptation procedure involved the works on the linguistic content of the items and testing psychometric properties of the Polish version of Skindex-29, including item characteristics, factorial structure, aspects of reliability and validity.

Material and methods

Two-hundred and ninety patients (63.4% women and 35.2% men) suffering from a range of skin conditions were recruited from several dermatological out-patient and in-patient clinics in Poland. Quality of life was measured using Skindex-29 and appropriate clinical data were collected.

Results

The global score of Skindex-29 showed the normal distribution. Cronbach's α reliability coefficients were found to be high to very high for all Skindex-29 indexes. Factor analysis yielded four factors, in contrast to the original version of the questionnaire, for which a three-factor solution had been reported. Skindex-29 validity was demonstrated by showing the differences in the quality of life scores across different diagnostic categories, and between in-patients and out-patients. Skindex-29 global scores were found to be significantly predicted by the localization of the skin lesions on legs, anogenital areas and palms.

Conclusions

The findings of this study support reliability and validity of the Polish version of Skindex-29, but they also raise questions to its three-factor structure.

Assessing adherence factors in patients under topical treatment: development of the Topical Therapy Adherence Questionnaire (TTAQ)

Medication adherence rates strongly depend on favorable disease outcomes. It is known that medication adherence rates are lower for topical treatment than for systemic treatment. However, to date no validated instrument for the assessment of adherence factors in topical treatment is available. The aim of this study was to develop a new questionnaire to assess adherence risk factors in topical treatment. The development of the Topical Therapy Adherence Questionnaire (TTAQ) and Patient Preference Questionnaire (PPQ) was based on a systematic literature review, and qualitative patient focus interviews and expert focus groups’ input. The psychometric properties and comprehensibility of the TTAQ and PPQ were assessed in a feasibility study with 59 psoriasis patients. Our first preliminary results indicate that the TTAQ and PPQ are psychometrically sound and reliable measures for the assessment of factors influencing topical treatment adherence. The questionnaires are currently being further developed and various parameters (e.g., time point of assessment) are currently being tested in an exploratory pilot study with ca. 2,000 psoriasis patients receiving topical treatment in a European clinical trial. The use of the final versions of TTAQ and PPQ in clinical practice may facilitate the early identification of specific non-adherence factors in patients under topical treatment, which could enable designing and applying adherence-enhancing interventions according to the patient’s individual needs.

Examining item content and structure in health status and health outcomes instruments: toward the development of a grammar for better understanding of the concepts being measured

OBJECTIVES

Health outcomes instruments assess diverse health concepts. Although item-level concepts are considered fundamental elements, the field lacks structures for evaluating and organizing them for decision making. This article proposes a grammar using item stems, response options, and recall periods to systematically identify item-level concepts. The grammar uses "core concept," "evaluative component," and "recall period" as intuitive terms for communicating with stakeholders. Better characterization of concepts is necessary for classifying instrument content and linking it to treatment benefit.

METHODS

Items in 2 generic and 21 disease-specific instruments were evaluated to develop and illustrate the use of the grammar. Concepts were assigned International Classification of Functioning, Disability and Health codes for exploring the value that the grammar and a classification system add to the understanding of content across instruments.

RESULTS

The 23 instruments include many core concepts; emotional function is the only concept assessed in all instruments. Concepts in disease-specific instruments show obvious patterns; for example, arthritis instruments focus on physical function. The majority of instruments used the same response options across all items, with five-point scales being the most common. Most instruments used one recall period for all items. Shorter recall periods were used for conditions associated with "flares," such as chronic obstructive pulmonary disease and "skin disease." Every diagnosis, however, showed variation across instruments in the recall period used.

CONCLUSIONS

This analysis indicates the proposed grammar's potential for discerning the conceptual content within and between health outcomes instruments and illustrates its value for improving communication between stakeholders and for making decisions related to treatment benefit.

Topical treatments for chronic plaque psoriasis

BACKGROUND

Chronic plaque psoriasis is the most common type of psoriasis, and it is characterised by redness, thickness, and scaling. First-line management of chronic plaque psoriasis is with topical treatments, including vitamin D analogues, topical corticosteroids, tar-based preparations, dithranol, salicylic acid, and topical retinoids.

OBJECTIVES

To compare the effectiveness, tolerability, and safety of topical treatments for chronic plaque psoriasis, relative to placebo, and to similarly compare vitamin D analogues (used alone or in combination) with other topical treatments.

SEARCH METHODS

We updated our searches of the following databases to February 2011: the Cochrane Skin Group Specialised Register, CENTRAL in The Cochrane Library (2011, Issue 2), MEDLINE (from 1948), EMBASE (from 1980), Science Citation Index (from 2008), Conference Proceedings Citation Index - Science (from 2008), BIOSIS (from 1993), Dissertation Abstracts via DialogClassic (all publication years), and Inside Conferences (all publication years).We identified ongoing and unpublished studies from the UK Clinical Research Network Study Portfolio and the metaRegister of Controlled Trials. We checked the bibliographies of published studies and reviews for further references to relevant trials, and we contacted trialists and companies for information about newly published studies.A separate search for adverse effects was undertaken in February 2011 using MEDLINE and EMBASE (from 2005).Final update searches for both RCTs and adverse effects were undertaken in August 2012. Although it has not been possible to incorporate RCTs and adverse effects studies identified through these final searches within this review, we will incorporate these into the next update.

SELECTION CRITERIA

Randomised trials comparing active topical treatments against placebo or against vitamin D analogues (used alone or in combination) in people with chronic plaque psoriasis.

DATA COLLECTION AND ANALYSIS

One author extracted study data and assessed study quality. A second author checked these data. We routinely contacted trialists and companies for missing data. We also extracted data on withdrawals and on local and systemic adverse events. We defined long-term trials as those with a duration of at least 24 weeks.

MAIN RESULTS

This update added 48 trials and provided evidence on 7 new active treatments. In total, the review included 177 randomised controlled trials, with 34,808 participants, including 26 trials of scalp psoriasis and 6 trials of inverse psoriasis, facial psoriasis, or both. The number of included studies counted by Review Manager (RevMan) is higher than these figures (190) because we entered each study reporting a placebo and an active comparison into the 'Characteristics of included studies' table as 2 studies.When used on the body, most vitamin D analogues were significantly more effective than placebo, with the standardised mean difference (SMD) ranging from -0.67 (95% CI -1.04 to -0.30; 1 study, 119 participants) for twice-daily becocalcidiol to SMD -1.66 (95% CI -2.66 to -0.67; 1 study, 11 participants) for once-daily paricalcitol. On a 6-point global improvement scale, these effects translate into 0.8 and 1.9 points, respectively. Most corticosteroids also performed better than placebo; potent corticosteroids (SMD -0.89; 95% CI -1.06 to -0.72; I² statistic = 65.1%; 14 studies, 2011 participants) had smaller benefits than very potent corticosteroids (SMD -1.56; 95% CI -1.87 to -1.26); I² statistic = 81.7%; 10 studies, 1264 participants). On a 6-point improvement scale, these benefits equate to 1.0 and 1.8 points, respectively. Dithranol, combined treatment with vitamin D/corticosteroid, and tazarotene all performed significantly better than placebo.Head-to-head comparisons of vitamin D for psoriasis of the body against potent or very potent corticosteroids had mixed findings. For both body and scalp psoriasis, combined treatment with vitamin D and corticosteroid performed significantly better than vitamin D alone or corticosteroid alone. Vitamin D generally performed better than coal tar, but findings relative to dithranol were mixed. When applied to psoriasis of the scalp, vitamin D was significantly less effective than both potent corticosteroids and very potent corticosteroids. Indirect evidence from placebo-controlled trials supported these findings.For both body and scalp psoriasis, potent corticosteroids were less likely than vitamin D to cause local adverse events, such as burning or irritation. Combined treatment with vitamin D/corticosteroid on either the body or the scalp was tolerated as well as potent corticosteroids, and significantly better than vitamin D alone. Only 25 trials assessed clinical cutaneous dermal atrophy; few cases were detected, but trials reported insufficient information to determine whether assessment methods were robust. Clinical measurements of dermal atrophy are insensitive and detect only the most severe cases. No comparison of topical agents found a significant difference in systemic adverse effects.

AUTHORS' CONCLUSIONS

Corticosteroids perform at least as well as vitamin D analogues, and they are associated with a lower incidence of local adverse events. However, for people with chronic plaque psoriasis receiving long-term treatment with corticosteroids, there remains a lack of evidence about the risk of skin dermal atrophy. Further research is required to inform long-term maintenance treatment and provide appropriate safety data.

Measurement of health-related quality of life in dermatological research and practice: outcome of the EADV Taskforce on Quality of Life

In the last decade, the importance of the measurement of health-related quality of life (HRQoL) has grown significantly. Today, HRQoL measurement is generally considered to be important in clinical trials, in the assessment of disease severity, in patient management and in the field of health economics. Therefore, a good understanding of the concept of HRQoL and its measurement instruments is a prerequisite for both researchers and clinicians. The European Academy for Dermatology and Venereology (EADV) Taskforce on Quality of Life encourages the application of HRQoL instruments in research and clinical practice, and with this manuscript, the Taskforce aims to contribute to the quality of this application. In dermatology, a large number of HRQoL instruments exist and herewith, we summarize the most commonly used generic and dermatology-specific HRQoL instruments. Information is given on the most important psychometric characteristics of these instruments, including: scale structure, reliability, validity and responsiveness. Furthermore, a flow chart is provided to support researchers and clinicians in selecting an existing instrument or, in case an appropriate instrument does not exist, in finding alternative solutions. The present manuscript is the first of a series of manuscripts to be written on behalf of the EADV Taskforce on Quality of Life, aiming to contribute to the scientific knowledge and measurement of patient reported outcomes in dermatological research and practice.

Validation of a new tool to assess health-related quality of life in psoriasis: the PSO-LIFE questionnaire

Background

Several questionnaires have been used to measure health related quality of life (HRQoL) in patients with psoriasis, few have been adapted for use in Spain; none of them was developed specifically for the Spanish population. The purpose of the study was to validate and assess the sensitivity to change of a new questionnaire to measure HRQOL in patients with psoriasis (PSO-LIFE).

Methods

Observational, prospective, multicenter study performed in centers around Spain. Patients with active or inactive psoriasis completed the PSO-LIFE together with other Dermatology Quality of Life Index (DLQI) and Psoriasis Disability Index (PDI). A control group of patients with urticaria or atopic dermatitis was also included. Internal consistency and test-retest reliability of the PSO-LIFE were assessed by calculating Cronbach’s alpha and Intraclass Correlation Coefficient (ICC). Validity was assessed by examining factorial structure, the capacity to discriminate between groups, and correlations with other measures. Sensitivity to change was measured using effect sizes.

Results

The final sample included for analysis consisted of 304 patients and 56 controls. Mean (SD) age of psoriasis patients was 45.3 (14.5) years compared to 38.8 (14) years for controls (p < 0.01). Cronbach’s alpha for the PSO-LIFE was 0.95 and test-retest reliability using the ICC was 0.98. Factor analysis showed the questionnaire to be unidimensional. Mean (SD) PSO-LIFE scores differed between patients with psoriasis and controls (64.9 [22.5] vs 69.4 [17.3]; p < 0.05), between those with active and inactive disease (57.4 [20.4] vs 76.4 [20.6]; p < 0.01), and between those with visible and non-visible lesions (63.0 [21.9] vs. 74.8 [23.9]; p < 0.01). The correlation between PSO-LIFE and PASI scores was moderate (r = −0.43) while correlations with DLQI and PDI dimensions ranged from moderate to high (between 0.4 and 0.8). Effect size on the PSO-LIFE in patients reporting ‘much improved’ health status at study completion was 1.01 (large effect size).

Conclusions

The present results provide substantial support for the reliability, validity, and responsiveness of the PSO-LIFE questionnaire in the population for which it was designed.

Quality-of-life instruments: evaluation of the impact of psoriasis on patients

The negative impact of psoriasis on a patient's quality of life (QoL) is well documented in the literature. Patients often suffer poor self-esteem, difficulties in social interactions, and significant psychological distress. It is, therefore, critically important that a clinician evaluate the extent to which the disease impacts a patient's QoL. This chapter reviews several validated and reliable generic, dermatology-specific, and disease-specific QoL instruments useful in measuring the impact of psoriasis on patient's QoL. These QoL instruments can be especially helpful in identifying those patients who would most benefit from systemic or biologic therapy.

Reliability and validity of the Chinese version of the Psoriasis Disability Index (PDI) in Chinese patients with psoriasis

Background

The Psoriasis Disability Index (PDI) is a widely used instrument to measure the impact of psoriasis on patients. There has not been psychometric evaluation of the Chinese version of PDI. The aim of this study was to evaluate its reliability and validity among Chinese patients with psoriasis.

Methods

A multi-center, cross-sectional study was conducted at 9 hospitals including patients aged 18 years and over. Reliability was determined by internal consistency using Cronbach’s alpha. Validity was assessed through convergent validity and known groups validity. Dimensionality of the PDI was examined by exploratory factor analysis in working patients and nonworking patients respectively.

Results

In all, 831 patients were studied. Internal consistency of the PDI was satisfactory. Cronbach’s alpha coefficient was 0.91 for the total score and over 0.70 for each subscale of the PDI. Evidence of convergent validity of the PDI was proved by excellent and moderate to good correlations with the Dermatology Life Quality Index (DLQI) and four subscales of the Short Form-36 (SF-36) (role-physical, bodily pain, social functioning, and role-emotional): r = 0.51-0.78. Known groups validity was confirmed that the PDI score discriminated well among patients with different severity of psoriasis. The dimensionality of the PDI was determined by the presence of two-factor structure for working patients and three-factor structure for nonworking patients which accounted for 57.3% and 62.3% of the variance respectively.

Conclusion

The Chinese version of the PDI is a reliable and valid instrument to assess the impact of psoriasis on patients’ lives and could be used in future quality of life assessment of Chinese patients with psoriasis.

Psychometric properties of the Chinese version of Dermatology Life Quality Index (DLQI) in 851 Chinese patients with psoriasis

BACKGROUND

The Dermatology Life Quality Index (DLQI) is one of the most frequently used scales to evaluate the impact of skin disease on patients' quality of life (QoL). There has not been psychometric evaluation of the Chinese version of DLQI in Chinese patients with psoriasis.

OBJECTIVE

The objective of this study was to evaluate the psychometric properties of the Chinese version of DLQI.

METHODS

Patients with psoriasis (≥ 18 years old) visiting nine hospitals in various regions of China were enrolled in the study. The DLQI, Psoriasis Disability Index (PDI) and Health Survey Short Form (SF-36) were completed. Severity of psoriasis was assessed by the Psoriasis Area Severity Index (PASI). Reliability was estimated by internal consistency. Validity was assessed using known-groups comparison, convergent validity and construct validity.

RESULTS

In all, 851 patients were included in the study. The internal consistency reliability of the DLQI was high (Cronbach's alpha = 0.91). Known-groups comparison showed that the DLQI discriminated well among patients who differed in age, geographical region, duration of psoriasis and the PASI score. Evidence of convergent validity of the DLQI was proved by high correlations with the PDI and four subscales of SF-36 (role-physical, bodily pain, social functioning and role-emotional): r = 0.52-0.78. Construct validity was proved by the presence of one-factor structure that accounted for 55.9% of the variance and fitted well into the unidimensional model.

CONCLUSION

The Chinese version of DLQI is a reliable and valid measure to assess patient-reported impact of skin disease and could be used in QoL and health outcome studies on Chinese psoriasis patients.

Can we rely on the Dermatology Life Quality Index as a measure of the impact of psoriasis or atopic dermatitis?

The Dermatology Life Quality Index (DLQI) is a widely used health-related quality of life measure. However, little research has been conducted on its dimensionality. The objectives of the current study were to apply Rasch analysis to DLQI data to determine whether the scale is unidimensional, to assess its measurement properties, test the response format, and determine whether the measure exhibits differential item functioning (DIF) by disease (atopic dermatitis versus psoriasis), gender, or age group. The results show that there were several problems with the scale, including misfitting items, DIF by disease, age, and gender, disordered response thresholds, and inadequate measurement of patients with mild illness. As the DLQI did not benefit from the application of Rasch analysis in its development, it is argued that a new measure of disability related to dermatological disease is required. Such a measure should use a coherent measurement model and ensure that items are relevant to all potential respondents. The current use of the DLQI as a guide to treatment selection is of concern, given its inadequate measurement properties.