Validity study for the stigmatization experience in atopic dermatitis and psoriatic patients

Efficacy and safety of apremilast in patients with moderate-to-severe genital psoriasis: Results from DISCREET, a phase 3 randomized, double-blind, placebo-controlled trial

BACKGROUND

Genital psoriasis can be stigmatizing, is highly prevalent among patients with psoriasis, and has limited treatment options. Apremilast is a unique oral immunomodulating phosphodiesterase 4 inhibitor approved for psoriasis treatment.

OBJECTIVE

To assess the efficacy and safety of apremilast 30 mg twice daily in patients with genital psoriasis.

METHODS

DISCREET, a phase 3, placebo-controlled trial (NCT03777436), randomized patients with moderate-to-severe genital psoriasis (stratified by affected body surface area <10% or ≥10%) to apremilast or placebo for a 16-week period, followed by an apremilast extension period. Week 16 results are presented.

RESULTS

Patients were randomized to apremilast (n = 143) or placebo (n = 146). At Week 16, 39.6% and 19.5% of apremilast and placebo patients, respectively, achieved a modified static Physician Global Assessment of Genitalia response (primary endpoint; score of 0/1, ≥2-point reduction); treatment difference was significant (20.1%, P = .0003). Improvements in genital signs and symptoms, skin involvement, and quality of life were observed. Common treatment-emergent adverse events were diarrhea, headache, nausea, and nasopharyngitis.

LIMITATIONS

Lack of active-comparator.

CONCLUSIONS

Apremilast demonstrated statistically and clinically meaningful genital Physician Global Assessment responses and improvement of signs, symptoms, severity, and quality of life in this first randomized, controlled study of an oral systemic treatment in patients with genital psoriasis.

Comparative effectiveness of biologics for patients with moderate-to-severe psoriasis and special area involvement: week 12 results from the observational Psoriasis Study of Health Outcomes (PSoHO)

Introduction

Psoriasis localized at the scalp, face, nails, genitalia, palms, and soles can exacerbate the disease burden. Real-world studies comparing the effectiveness of treatments for these special areas are limited.

Methods

Psoriasis Study of Health Outcomes (PSoHO) is an international, prospective, non-interventional, study comparing the effectiveness of anti-interleukin (IL)-17A biologics (ixekizumab and secukinumab) compared to other approved biologics and the pairwise comparative effectiveness of ixekizumab relative to five other individual biologics for patients with moderate-to-severe psoriasis. To determine special area involvement, physicians answered binary questions at baseline and week 12. The proportion of patients who achieved special area clearance at week 12 was assessed. Missing outcome data were imputed as non-response. Comparative treatment analyses were conducted using frequentist model averaging.

Results

Of the 1,978 patients included, 83.4% had at least one special area involved at baseline with the scalp (66.7%) as the most frequently affected part, followed by nails (37.9%), face/neck (36.9%), genitalia (25.6%), and palms and/or soles (22.2%). Patients with scalp, nail, or genital, but not palmoplantar or face/neck psoriasis, had significantly higher odds of achieving clearance at week 12 in the anti-IL-17A cohort compared to the other biologics cohort. Patients with scalp psoriasis had a 10-20% higher response rate and significantly greater odds (1.8-2.3) of achieving clearance at week 12 with ixekizumab compared to included biologics.

Conclusion

Biologics demonstrate a high level of clearance of special areas at week 12 in a real-world setting. Patients with scalp, nail, or genital involvement have significantly higher odds of clearance at week 12 with anti-IL-17A biologics compared to other biologics.

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.

Clinical evidence of therapy for genital psoriasis by biologic agents

Data in the scientific literature on the use of biologic therapy in localized forms of psoriasis elucidate mostly the problems of treatment of palmoplantar, scalp psoriasis and nail psoriasis. At the same time, the number of scientific data on the effect of biological therapy on genital psoriasis is extremely limited. Important that the quality of life on patients with genital psoriasis has very low level, which indicates a significant influence on the psychological and social well-being. At the same time, the limited number of therapeutic approaches makes this problem even more urgent. Unfortunately, special clinical trials for such patients are rather an exception. Ixekizumab has been reported an effectiveness for patients with anogenital psoriasis. New data on the comparative efficacy of ixekizumab and secukinumab give hope us for new opportunity for the treatment of genital psoriasis.

Stigma in visible skin diseases - a literature review and development of a conceptual model

The burden of visible skin diseases (VSDs) includes not only physical symptoms but also psychosocial consequences such as depression, anxiety, impaired quality of life and low self-esteem. Stigmatization was shown to play a major role in people with skin diseases. The aim of the study was to review the evidence for the components, drivers and impacts of (self-)stigma, and to organize the data into a series of conceptual models. A targeted literature search was conducted to identify studies on (self-)stigma in relation to VSD. Conceptual models of stigma in VSDs were developed from existing generic conceptual models for VSD and of generic conceptual models of stigma and were refined after discussion with a board of experts, patient advocacy groups, clinicians and researchers. A total of 580 references were identified, of which 56 references were analysed and summarized. Two conceptual models of stigma were identified: one with external stigma and self-stigma dimensions, the other for self-stigma in mental health. These models were adapted to allow a complete description of stigma in VSDs. For this, a distinction was made between 'discrimination' and 'impact'. Finally, five models were developed: macro-overview; stigma, impact and socio-demographics; stigma, impact and disease characteristics; stigma, impact and quality of life; and stigma, impact and coping. Gaps were identified in available quantitative evidence. To our knowledge, this is the first conceptual model of stigma in VSDs. The model will help to standardize evaluation of stigma and to enhance empirical evaluation of anti-stigma interventions in VSDs. Further research should be conducted to develop a more complete model in stigma due to significant gaps in existing evidence, particularly including the stigma in others (external stigma) and also to cover a broader range of VSDs as their impact on particular dimensions of stigma differs.

A Randomized Controlled Ixekizumab Vs Secukinumab Trial to Study the Impact on Sexual Activity in Adult Patients with Genital Psoriasis

Introduction: There is limited data on the effects of biologic therapies on genital psoriasis and sexual activity. Recently, Ixekizumab was reported to be effective. Aim: To compare the efficacy of ixekizumab and secukinumab for the treatment of genital psoriasis and sexual inadequacy in adult patients with moderate-to-severe psoriasis. Patients and methods: We assessed adult patients with moderate-to-severe psoriasis having genital involvement. They were randomly assigned in a 1:1 ratio to receive either ixekizumab (80 mg/2 weeks after 160-mg initial dose) or secukinumab (300 mg subcutaneous injection at Weeks 0, 1, 2, 3, and 4 then every 4 weeks). The severity was assessed using Genital Psoriasis Symptoms Scale (GPSS), and impact on sexual health by evaluating the Massachusetts General Hospital-Sexual Functioning Questionnaire (MGH-SFQ). Results: Twenty eight patients on ixekizumab, and 26 on secukinumab showed improvement in genital psoriasis symptoms, beginning week 2 (GPSS total and individual items), and from week 4 onwards, improvement in sexual activity was seen with both drugs. Conclusion: Both genital psoriasis symptoms and impact on sexual activity improved rapidly and significantly with both the IL-17 inhibitors. Limitations included small number of patients and lack of follow-up period.

Stigmatization and Quality of Life in Patients with Psoriasis

Introduction

Each dermatological condition associated with the presence of visible skin lesions can evoke the following psychological response of the patient: shame, anxiety, anger, or even depression. Psoriasis may additionally be a cause of social rejection, which significantly impairs a patient’s private life and social functioning, and may contribute to stigmatization, alienation, and deterioration of their quality of life. The aim of the study was to determine the level of stigmatization and the quality of life of persons with psoriasis in relation to sociodemographic characteristics.

Methods

The study, which included 166 patients with plaque psoriasis, was carried out with the 33-item Feelings of Stigmatization Questionnaire, Dermatology Life Quality Index (DLQI), and a dedicated sociodemographic survey.

Results

Compared with women, men had higher stigmatization scores in the “Feeling of being flawed” domain (p = 0.0362), and patients up to 30 years of age scored higher on the “Guilt and shame” domain (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\bar{x}$$\end{document}x¯ = 17.1 points) than those older than 30 years (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\bar{x}$$\end{document}x¯ = 14.6 points). Also, persons with visible skin lesions presented with higher stigmatization levels in the “Guilt and shame” domain than those without (p = 0.0028). Quality of life in persons with psoriasis did not depend on sociodemographic parameters but correlated significantly with two stigmatization domains, “Sensitivity to the opinions of others” (R = 0.31; p = 0.0030) and “Positive attitudes” (R = 0.27; p = 0.0115).

Conclusions

As stigmatization is a social problem, only greater social awareness of psoriasis may contribute to better understanding and broader acceptance of patients with this dermatosis. To help them to cope with the stigmatization and hence to improve their quality of life, persons with psoriasis should be provided with psychological counselling.

The impact of genital psoriasis on quality of life: a systematic review

Psoriasis is a chronic immune-mediated inflammatory disease with significant medical and psychological comorbidities. In addition to having increased cardiovascular risk and mortality, psoriasis patients are more likely to be depressed, anxious, and endorse suicidal ideation than the general population. These patients often have low self-esteem and feel stigmatized due to their skin disease, which can prevent them from pursuing relationships, dating, and attending social activities. Up to 63% of adult psoriasis patients experience psoriatic lesions on their genital area during their lifetime, but often do not discuss these issues with their physicians due to embarrassment, stigmatization, or shyness about this sensitive location. However, psoriasis in sensitive areas, such as the genitals, may result in quality of life impairment greater than that of patients with psoriasis elsewhere on their body, particularly in respect to romantic relationships, intimacy, and sexual function. This article evaluates the current literature regarding the impact of genital psoriasis on the quality of life of affected patients.

Stress, itch and quality of life in chronic urticaria females

Introduction

Chronic urticaria (CU) belongs to a group of psychodermatological disorders, thus stress can play a significant role in this dermatosis onset and/or exacerbation. On the other hand, the disease itself accompanied by itch, may be a source of distress and could worsen patients' quality of life (QoL).

Aim

The first goal of our study was to compare stress intensity between CU subjects and the control group. The second aim was to investigate the relationships between disease-related parameters (CU severity, itch) and psychological variables (stress and QoL) in CU patients.

Material and methods

Forty-six female patients with CU participated in our study. Thirty-three healthy females constituted a control group. The following methods were applied: Urticaria Activity Score (UAS), Itch Severity Evaluation Questionnaire, Visual analogue scale (VAS), Social Readjustment Rating Scale (SRRS) and the Chronic Urticaria Quality of Life Questionnaire (CU-Q2oL).

Results

Chronic urticaria patients demonstrated a significantly higher stress level in comparison to the control group (z = 2.699; p < 0.001). Regarding the total pruritus score, all CU-Q2oL dimensions were affected, except for subscale swelling/mental status. The strongest link was revealed between global itch and QoL subscale embarrassment (r = 0.51, p < 0.001). There were also statistically significant correlations between stress (VAS scale and SRRS) and QoL (all at least p < 0.05).Conclusions: Taking into account the significant pruritus contribution to QoL impairment, it would be worth employing itch-coping trainings in the CU group. As a consequence, feeling of self-control and self-efficacy could be enhanced, thus resulting in the well-being improvement.

Pharmacotherapeutic approaches for treating psoriasis in difficult-to-treat areas

INTRODUCTION

Despite great therapeutic advancements in psoriasis, four notable difficult-to-treat areas including the scalp, nails, intertriginous (including genitals), and palmoplantar regions, pose a challenge to both physicians and patients. Localized disease of these specific body regions inflicts a significant burden on patients' quality of life and requires an adequate selection of treatments.

AREAS COVERED

This manuscript discusses appropriate therapies and important treatment considerations for these difficult-to-treat areas based on the available clinical data from the literature.

EXPERT OPINION

Clinical trials assessing therapies for the difficult-to-treat areas have been inadequate. With the first biological clinical trial for genital psoriasis pending publication, it is with hope that other biological agents will be evaluated for region-specific psoriasis. A greater understanding of the genetic and immunologic aspects of regional psoriasis, as well as identification of unique biomarkers, will further guide management decisions. For example, the recent discovery of the IL-36 receptor gene for generalized pustular psoriasis may prove valuable for other forms of psoriasis. Ultimately, identification of the most beneficial treatments for each psoriasis subtype and difficult-to-treat area will provide patients with maximal quality of life.

Psychosocial aspects of rosacea with a focus on anxiety and depression

Background

Rosacea is a common, chronic skin condition characterized by facial redness and inflammatory lesions. The disease can lead to social stigmatization and may significantly reduce the quality of life of patients. Psychosocial impact of rosacea can be severe and debilitating; however, it is still underestimated.

Objective

This paper provides a literature review focused on depression and anxiety in patients with rosacea.

Conclusion

Rosacea patients have an increased risk of developing depression and anxiety and tend to avoid social situations. However, there are still limited data on this condition. Effective treatment of clinical symptoms brings significant improvement in psychological symptoms. Further studies should be conducted to investigate in more detail the psychological impact of rosacea. In addition, improvement of the efficacy of rosacea treatment is still needed.

Associations between site of skin lesions and depression, social anxiety, body-related emotions and feelings of stigmatization in psoriasis patients

INTRODUCTION

Research has demonstrated a link between psoriasis and a multitude of psychological impairments; however, relatively few studies have examined the importance of site of skin lesions for negative psychological outcomes in psoriasis patients.

AIM

To investigate relationships between anatomical location of psoriatic lesions and experiences of stigmatization, negative emotional attitude towards the body, depression and social anxiety.

MATERIAL AND METHODS

Adult psoriasis patients (N = 193) completed the Stigmatization Scale, the Body Emotions Scale, the Beck Depression Inventory and the Social Anxiety Questionnaire. The body surface area index was used to assess the location and extent of psoriasis.

RESULTS

Feelings of stigmatization were found to be most closely related to the presence of psoriatic lesions on the chest, and the arms and hands. Higher levels of social anxiety were found to be most closely related to the location of psoriatic lesions on the head and neck. Negative emotional attitude towards the body was found to be most closely related to the location of psoriatic lesions on the arms and hands, and on the head and neck. Higher levels of depressive symptoms were most closely related to the presence of psoriatic lesions on the head and neck, the arms and hands, and the genital area.

CONCLUSIONS

The presence of psoriatic lesions on the head, neck, and chest, and also on the arms and hands and the genital area, should alert clinicians to a higher risk of psychological impairments. This may help to better recognize and prevent cumulative life course impairment.

The vicious cycle of itch and anxiety

Chronic itch is associated with increased stress, anxiety, and other mood disorders. In turn, stress and anxiety exacerbate itch, leading to a vicious cycle that affects patient behavior (scratching) and worsens disease prognosis and quality of life. This cycle persists across chronic itch conditions of different etiologies and even to some extent in healthy individuals, suggesting that the final common pathway for itch processing (the central nervous system) plays a major role in the relationship between itch and anxiety. Pharmacological and nonpharmacological treatments that reduce anxiety have shown promising anti-itch effects. Further research is needed to establish specific central mechanisms of the itch-anxiety cycle and provide new targets for treatment.

The Development of a Patient-Reported Outcome Measure for Assessment of Genital Psoriasis Symptoms: The Genital Psoriasis Symptoms Scale (GPSS)

INTRODUCTION

Patient-reported outcome measures (PROs) specific for genital psoriasis (GenPs) have not been described.

METHODS

In this cross-sectional, qualitative study in patients with moderate-to-severe GenPs, we sought to develop a PRO useful for GenPs symptom assessment. A literature review was performed to identify relevant psoriasis or GenPs symptoms and existing PROs that may be useful in the evaluation of symptom severity in GenPs patients. The literature review findings were discussed with clinicians, and then patients with GenPs.

RESULTS

Relevant psoriasis or GenPs symptoms from the literature review included itch, pain, scaling, redness/erythema, and stinging/burning. The validity of these symptoms for GenPs and potentially relevant PROs was corroborated by clinical experts. After gap analysis, a draft symptom scale consisting of Numeric Rating Scale (NRS) items was constructed. We then conducted interviews with GenPs patients (n = 20) to support content validity and use of the draft symptom NRS items in routine practice and in clinical trials. Participants identified and confirmed relevant symptoms and evaluated the utility of the draft PRO. A new PRO was developed: the Genital Psoriasis Symptoms Scale (GPSS). Cognitive debriefing and cultural adaptation/translation interviews with a second group of patients confirmed cultural appropriateness of the GPSS.

CONCLUSION

The GPSS may be useful for assessing symptoms before, during, and after treatment in routine clinical practice and in clinical trials involving patients with GenPs.

FUNDING

Eli Lilly & Company. Plain language summary available for this article.

Patients' Perspectives on the Impact of Genital Psoriasis: A Qualitative Study

Introduction

Plaque psoriasis is a chronic skin disease where genital involvement is relatively common. Yet health care providers do not routinely evaluate psoriasis patients for genital involvement and patients do not readily initiate discussion of it.

Methods

A qualitative study of 20 US patients with dermatologist-confirmed genital psoriasis (GenPs) and self-reported moderate-to-severe GenPs at screening was conducted to identify key GenPs symptoms and their impacts on health-related quality of life (HRQoL).

Results

Patients had a mean age of 45 years, 55% were female, and patients had high rates of current/recent moderate-to-severe overall (65%) and genital (70%) psoriasis. Patients reported the following GenPs symptoms: genital itch (100%), discomfort (100%), redness (95%), stinging/burning (95%), pain (85%), and scaling (75%). Genital itching (40%) and stinging/burning (40%) were the most bothersome symptoms. Impacts on sexual health included impaired sexual experience during sexual activity (80%), worsening of symptoms after sexual activity (80%), decreased frequency of sexual activity (80%), avoidance of sexual relationships (75%), and reduced sexual desire (55%). Negative effects on sexual experience encompassed physical effects such as mechanical friction, cracking, and pain as well as psychosocial effects such as embarrassment and feeling stigmatized. Males reported a higher burden of symptoms and sexual impacts. Other HRQoL impacts were on mood/emotion (95%), physical activities (70%), daily activities (60%), and relationships with friends and family (45%). These impacts significantly affected daily activities. Physical activities were affected by symptoms and flares, and increased sweat and friction worsened symptoms. Patients reported daily practices to control outcomes.

Conclusion

The high level of reported symptoms and sexual and nonsexual impacts reflects the potential burden of moderate-to-severe GenPs. GenPs can impact many facets of HRQoL and providers should evaluate their patients for the presence of genital psoriasis and its impact on their quality of life.

Funding

Eli Lilly and Company.

Electronic supplementary material

The online version of this article (doi:10.1007/s13555-017-0204-3) contains supplementary material, which is available to authorized users.

Background

Psoriasis is a skin disease that can cause itchy, raised red patches of skin. Currently, psoriasis cannot be cured but medicines can make the patches smaller or go away completely. The patches can occur anywhere on the body. Sometimes people get them in their genital area. However, people are sensitive about this area and may not tell their doctor. Their doctor may not look or ask either.

What We Did

We interviewed 20 men and women who had moderate-to-severe genital psoriasis. We asked about their health-related quality of life, including their sex life.

What We Learned

All 20 people said they had symptoms of itching and discomfort in their genital area. Most people also had symptoms of redness, stinging or burning, pain, and scaling (flaky skin). Most people said symptoms affected their sex life. Sexual activity was less comfortable. People had sexual activity less often. Physical reasons, such as pain, bothered some people. Emotional reasons, such as being embarrassed, bothered other people more. People said the genital psoriasis affected how they felt. For example, it made them stressed, angry, or sad. Genital psoriasis made physical activities such as walking and running more uncomfortable for many people, especially when symptoms “acted up.” Sweating a lot, wearing tight underwear, or working a long day could make symptoms worse too. About half the people spent less time with their family and friends because of their symptoms. People also did things to try to reduce their symptoms. Some people wore loose clothes or soaked in a bathtub every night or after sex. Other people carried cream (to stop the itch) with them all the time.

Conclusion

Other people may not experience what these 20 people did. However, having genital psoriasis can significantly impact someone’s life. Patients and doctors should talk about it.

Electronic supplementary material

The online version of this article (doi:10.1007/s13555-017-0204-3) contains supplementary material, which is available to authorized users.

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.

Asthma and atopic diseases in adolescence and antidepressant medication in middle age

This Swedish register-based cohort study examined whether asthma, hay fever and allergic dermatitis in late adolescence identified in the early 1970s are associated with antidepressant medication in middle age, between 2006 and 2009. After adjustment for childhood and adulthood sociodemographic characteristics, psychological, cognitive and physical function, and comorbidity, the magnitude of the associations diminished for asthma, while hay fever and atopic dermatitis retained associations. Hay fever and atopic dermatitis in adolescence have potentially important implications for future mental health, while asthma may already have influenced an individual's ability to cope with stress by late adolescence.

Feelings of stigmatization in patients with rosacea

BACKGROUND

Rosacea is a chronic facial disease that may lead to feelings of stigmatization, which can negatively impact psychological and social well-being.

OBJECTIVE

The aim of this study was to evaluate different aspects of rosacea that could contribute to feelings of stigmatization.

METHODS

An online survey of a representative sample of the adult population in the UK, France, Germany and US was conducted to identify patients with rosacea based on presence of three or more clinical features.

RESULTS

Among the patients who completed the survey (n = 807), mean age at first sign/symptom of rosacea was 31.3 ± 14.5 years; mean duration of disease was 102 ± 119 months. One-third of patients reported feelings of stigmatization (FS; n = 275). Male patients were more likely to experience FS (49% vs. 37.2% in non-FS population; P = 0.0037). Those with FS were more likely to avoid social situations (54.2% vs. 2.0%, P < 1.00^E-10 ) and had a higher rate of depression (36.7% vs. 21.1%, P < 1.00^E-10 ).

CONCLUSIONS

Stigmatization is important in the daily lives of those with rosacea and should be taken into consideration in the management of these patients.

Distribution pattern of psoriasis, anxiety and depression as possible causes of sexual dysfunction in patients with moderate to severe psoriasis

BACKGROUND:

Psoriasis may significantly impair sexual function. Depression and organic factors appear to play a key role in this relation. However, beyond genital psoriasis, the importance of the disease's distribution patterns has not been considered.

OBJECTIVES:

To research sexual function in psoriasis patients and investigate the roles of anxiety, depression and psoriasis' distribution patterns in sexual dysfunction.

METHODS:

A comparative study matched for sex and age was performed. Eighty patients with moderate to severe psoriasis and 80 healthy controls were included. The participants completed the Massachusetts General Hospital-Sexual Functioning Questionnaire, the Hospital Anxiety and Depression Scale, and the Self-Administered Psoriasis Area and Severity Index.

RESULTS:

Psoriasis was associated with sexual dysfunction, odds ratio=5.5 (CI 95% 2.6-11.3; p<0.001). Certain distribution patterns of psoriasis, involving specific body regions, were associated with an increase in sexual dysfunction in the group presenting the disease, odds ratio 7.9 (CI 95% 2.3-33.4; p<0.001). Multivariate logistic regression analysis identified anxiety and depression, and the involvement of these specific areas, as possible independent risk factors for sexual dysfunction in patients with moderate to severe psoriasis.

CONCLUSION:

This study identifies body areas potentially related to sexual dysfunction, independently of anxiety and depression, in psoriasis patients. The results suggest that the assessment of sexual dysfunction and the involvement of these body areas should be considered as disease severity criteria when choosing the treatment for psoriasis patients.

Risk of developing major depressive disorder and anxiety disorders among adolescents and adults with atopic dermatitis: a nationwide longitudinal study

BACKGROUND

Previous cross-sectional studies have suggested a comorbid association between atopic dermatitis (AD) and depressive disorder as well as anxiety disorders, but the temporal relationship was not determined.

METHODS

Using the Taiwan National Health Insurance Research Database, 8208 AD patients aged 12 and older without psychiatric history and age-/sex-matched (1:1) controls between 1998 and 2008 were enrolled in our study and followed to the end of 2011. Subjects who developed major depression, any depressive disorder, and anxiety disorders during the follow-up were identified.

RESULTS

The Cox regression analysis after adjusting for demographic data and atopic comorbidities demonstrated that patients with AD had an elevated risk of developing major depression (hazard ratio [HR]: 6.56, 95% confidence interval [CI]: 3.64-11.84), any depressive disorder (HR: 5.44, 95% CI: 3.99-7.44), and anxiety disorders (HR: 3.57, 95% CI: 2.55-4.98). Stratified by age group, both adolescents and adults with AD were prone to developing major depression (HR: 4.26, 95% CI: 1.39-13.13; HR: 7.56, 95% CI: 3.75-15.23), any depressive disorder (HR: 4.38, 95% CI: 2.09-9.18; HR: 5.66, 95% CI: 4.01-7.99), and anxiety disorders (HR: 5.40, 95% CI: 2.02-14.39; HR: 3.36, 95% CI: 2.38-4.80).

CONCLUSIONS

AD in both adolescence and adulthood increased the risk of developing major depression, any depressive disorder, and anxiety disorders in later life. Further studies would be required to clarify the possible underlying mechanism between AD and depression as well as anxiety disorders.

PCQoL

Background:

Pachyonychia congenita (PC) is a rare but often debilitating, dominantly inherited disorder. New treatments require more accurate instruments for evaluating changes in the quality of life in these patients.

Objectives:

This study was undertaken to develop and validate a quality of life questionnaire for PC patients (PCQoL).

Methods:

Relevant factors influencing quality of life in PC patients were identified and incorporated into the well-recognized, general questionnaire, the Dermatology Life Quality Index (DLQI), to establish a disease-specific measure, the PCQoL. Classical test theory (CTT) and Rasch analysis (RA) were used to analyze and validate the PCQoL.

Results:

CTT analysis established test–retest reliability and internal consistency for the PCQoL. Concurrent and construct validity for the DLQI and the PCQoL were also validated. Chi-square–based infit and outfit statistics indicated that the Rasch model fits the observed responses very well. RA reconfirmed reliability, internal consistency, reasonable homogeneity, construct validity, and the presence of three RA-based domains.

Conclusion:

The PCQoL questionnaire is a measure validated by both CTT and RA. It appears to be a valuable tool in measuring quality of life modifications in PC individuals with keratoderma.

Treatment of Vitiligo Patients by Excimer Laser Improves Patients’ Quality of Life

Background:

Vitiligo can negatively affect patients’ quality of life (QoL). Assessment of QoL provides relevant information about treatment benefits.

Objectives:

To examine the effects of excimer laser treatment on vitiligo patients’ QoL and to identify overall patient satisfaction. The literature review failed to show any study concerning the same field.

Methods:

A total of 134 vitiligo patients (with 386 lesions) were studied. The Dermatology Life Quality Index (DLQI) was used to assess the effect of excimer laser treatment on patients’ QoL. A visual analogue scale (VAS) was used to rate patients’ overall life satisfaction and disturbance.

Results:

Excimer laser treatment significantly improved QoL in vitiligo patients, with improvement observed in five of six DLQI domains. Treatment-induced changes in the VAS score showed a significant decline in life disturbance and improvement in life satisfaction. Multivariate analysis revealed that sex and treatment duration were independent factors influencing treatment outcomes.

Conclusions:

Treatment of vitiligo with excimer laser can positively influence patients’ QoL. Patients with multiple focal lesions should be treated by excimer laser even if some lesions may not show significant clinical improvement.

Disclosure and Experienced Social Support are not Related to Anxiety or Depression in a German HIV Patient Cohort

BACKGROUND

It is unclear to which extent the rate of disclosure of the diagnosis "HIV" to the social environment and the nature of experienced responses are correlated with the current mental health status of HIV-infected patients living in Germany.

MATERIALS AND METHODS

Eighty consecutive patients of two German HIV outpatient clinics were enrolled. Patients performed the Hospital Anxiety and Depression Scale (HADS) in its German version. Disclosure behaviour and the experienced responses after disclosing as perceived by the participants were assessed using a questionnaire. In addition, patients were asked to state whether they felt guilty for the infection on a 1-4 point Likert scale.

RESULTS

Pathological results on the anxiety scale were reached by 40% of male and 73% of female patients, and on the depression scale by 30% of male and 47% of female patients, thus significantly exceeding recently assessed values in the German general population, except for depression in males. None of the HADS scale results was interrelated either with the rate of disclosure or the experienced responses. 36% of patients reported to feel guilty for the infection, which was positively correlated with results from the HADS.

LIMITATION

The time since the single disclosure events was not assessed, and the subgroup of women was comparably small.

CONCLUSIONS

Despite substantial improvement in treatment, HIV-infected patients in Germany still suffer from an elevated level of anxiety and, in part, depression. However, mental health status was neither related with disclosure behaviour nor with experienced responses. We hypothesize that internal beliefs may play a more important role.

Cost-effectiveness model for a specific mixture of prebiotics in The Netherlands

The objective of this study was to assess the cost-effectiveness of the use of prebiotics for the primary prevention of atopic dermatitis in The Netherlands. A model was constructed using decision analytical techniques. The model was developed to estimate the health economic impact of prebiotic preventive disease management of atopic dermatitis. Data sources used include published literature, clinical trials and official price/tariff lists and national population statistics. The comparator was no supplementation with prebiotics. The primary perspective for conducting the economic evaluation was based on the situation in The Netherlands in 2009. The results show that the use of prebiotics infant formula (IMMUNOFORTIS(®)) leads to an additional cost of € 51 and an increase in Quality Adjusted Life Years (QALY) of 0.108, when compared with no prebiotics. Consequently, the use of infant formula with a specific mixture of prebiotics results in an incremental cost-effectiveness ratio (ICER) of € 472. The sensitivity analyses show that the ICER remains in all analyses far below the threshold of € 20,000/QALY.

CONCLUSION

This study shows that the favourable health benefit of the use of a specific mixture of prebiotics results in positive short- and long-term health economic benefits. In addition, this study demonstrates that the use of infant formula with a specific mixture of prebiotics is a highly cost-effective way of preventing atopic dermatitis in The Netherlands.

Canadian guidelines for the management of plaque psoriasis: overview

New clinical treatment guidelines for plaque psoriasis, written by a panel of 16 Canadian dermatologists, were recently published online. These Canadian Guidelines for the Management of Plaque Psoriasis are evidence based and free of any influence from corporate sponsors and have been endorsed by the Canadian Dermatology Association (CDA). The Guidelines offer treatment recommendations for mild and moderate to severe body psoriasis, as well as for psoriasis affecting specific areas of the skin, such as the facial, flexural, and genital areas; nails; scalp; and palms and soles. The present overview describes the genesis and contents of the Guidelines, which are available in full through the CDA at <http://www.dermatology.ca/guidelines/cdnpsoriasisguidelines.pdf> (English) or <http://www.dermatology.ca/french/psoriasisguidelines.html> (French).

Quality of life and sexual health in patients with genital psoriasis

BACKGROUND

Knowledge about quality of life and sexual health in patients with genital psoriasis is limited.

OBJECTIVES

We studied quality of life and sexual function in a large group of patients with genital psoriasis by means of validated questionnaires. In addition, we evaluated whether sufficient attention is given by healthcare professionals to sexual problems in patients with psoriasis, as perceived by the patients.

METHODS

A self-administered questionnaire was sent to 1579 members of the Dutch Psoriasis Association. Sociodemographic patient characteristics, medical data and scores of several validated questionnaires regarding quality of life (Dermatology Life Quality Index) and sexual health (Sexual Quality of Life Questionnaire for use in Men, International Index of Erectile Function, Female Sexual Distress Scale and Female Sexual Function Index) were collected and analysed.

RESULTS

This study (n = 487) shows that psoriasis has a detrimental effect on quality of life and sexual health. Patients with genital lesions reported even significantly worse quality of life than patients without genital lesions (mean ± SD quality of life scores 8·5 ± 6·5 vs. 5·5 ± 4·6, respectively, P < 0·0001). Sexual distress and dysfunction are particularly prominent in women (reported by 37·7% and 48·7% of the female patients, respectively). Sexual distress is especially high when genital skin is affected (mean ± SD sexual distress score in patients with genital lesions 16·1 ± 12·1 vs. 10·1 ± 9·7 in patients without genital lesions, P = 0·001). The attention given to possible sexual problems in the psoriasis population by healthcare professionals is perceived as insufficient by patients.

CONCLUSIONS

In addition to quality of life, sexual health is diminished in a considerable number of patients with psoriasis and particularly women with genital lesions have on average high levels of sexual distress. We underscore the need for physicians to pay attention to the impact of psoriasis on psychosocial and sexual health when treating patients for this skin disease.

Guidelines of care for the management of psoriasis and psoriatic arthritis: section 6. Guidelines of care for the treatment of psoriasis and psoriatic arthritis: case-based presentations and evidence-based conclusions

Psoriasis is a common, chronic, inflammatory, multisystem disease with predominantly skin and joint manifestations affecting approximately 2% of the population. In the first 5 parts of the American Academy of Dermatology Psoriasis Guidelines of Care, we have presented evidence supporting the use of topical treatments, phototherapy, traditional systemic agents, and biological therapies for patients with psoriasis and psoriatic arthritis. In this sixth and final section of the Psoriasis Guidelines of Care, we will present cases to illustrate how to practically use these guidelines in specific clinical scenarios. We will describe the approach to treating patients with psoriasis across the entire spectrum of this fascinating disease from mild to moderate to severe, with and without psoriatic arthritis, based on the 5 prior published guidelines. Although specific therapeutic recommendations are given for each of the cases presented, it is important that treatment be tailored to meet individual patients' needs. In addition, we will update the prior 5 guidelines and address gaps in research and care that currently exist, while making suggestions for further studies that could be performed to help address these limitations in our knowledge base.

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.

The course of life of patients with childhood atopic dermatitis

Atopic dermatitis mainly covers the period of infancy to adulthood, an important period in the development of an individual. The impairment of quality of life and the psychological wellbeing of children with atopic dermatitis have been well documented but so far no data exist about the impact of atopic dermatitis in childhood on fulfilling age-specific developmental tasks and achieving developmental milestones during this period, referred to as the course of life. The aims of this study were to: (i) assess the course of life and define the disease-related consequences in young adult patients with childhood atopic dermatitis and (ii) determine whether the severity of atopic dermatitis is predictive for the course of life, the disease-related consequences and quality of life later in life. Adult patients who grew up with atopic dermatitis were asked to complete a medical history questionnaire, the Skindex-29, the "course of life" questionnaire and a subjective disease-specific questionnaire. Patients with severe atopic dermatitis in childhood showed a significant delayed social development in their course of life. The results of the disease-specific questionnaire demonstrated remarkable high percentages of psycho-social consequences and physical discomfort caused by atopic dermatitis in childhood. Patients showed a severely negative impact of atopic dermatitis on their current quality of life. This is the first study that applied the "course of life" questionnaire in atopic dermatitis. More insight in the course of life, disease-specific consequences and quality of life of atopic dermatitis is of high importance, especially in case of severe atopic dermatitis.

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.