Dimensions of stigmatization in patients with psoriasis in a "Questionnaire on Experience with Skin Complaints'

Investigating the Role of Upward Comparisons and Self-compassion on Stigma in People With Acne: Cross-sectional Study

BACKGROUND

The use of image-laden social media is hypothesized as being implicated in psychological distress in individuals with conditions affecting their appearance. However, relatively little is known about the mechanisms involved in this relationship.

OBJECTIVE

This cross-sectional study examined the relationship between photo-orientated social media use and feelings of stigmatization in adults with acne, and tested whether upward skin comparisons mediate and self-compassion moderates this relationship.

METHODS

Adults (N=650) with acne symptoms completed web-based measures of social media use (daily Facebook or Instagram use, Facebook function use), self-compassion, skin appearance comparisons, and internalized stigmatization.

RESULTS

Moderated-mediation and mediation analyses indicated that there was a significant indirect effect of Facebook photo use on stigmatization, mediated by upward appearance comparisons (estimation of indirect effect 11.03, SE 5.11, 95% CI 1.19-21.12). There was no significant relationship between Instagram use and feelings of stigmatization (estimation of indirect effect 0.0002, SE 0.005, 95% CI -0.011 to 0.009), yet upward appearance comparisons predicted feelings of stigmatization (B=0.99, P<.001). Self-compassion did not moderate the indirect or direct relationships between photo-orientated social media use and stigma. However, self-compassion was negatively correlated with upward appearance comparisons and feelings of stigmatization in both Facebook and Instagram users.

CONCLUSIONS

The way that individuals engage with social media, and in particular make appearance comparisons, should be considered when working with individuals with skin-related distress. Interventions aimed at boosting self-compassion and reducing appearance comparisons may provide avenues for protecting against feelings of stigma.

Towards a better understanding of the social stigma of facial difference

Facial difference (FD) is not only an individual experience; it is inherently social, reflecting interactions between social norms and individual attitudes. Often FD is stigmatized. In this paper, we employ a widely used stigma framework, namely the social stigma framework put forth by Pryor and Reeder (2011), to unpack the stigma of FD. This framework posits that there are four forms of stigma: public stigma, self-stigma, stigma by association, and structural stigma. We first discuss the social and psychological literature on FD as it pertains to these various forms of stigma. We then describe coping approaches for FD stigma. Lastly, we delineate evidence-based methods for addressing the various forms of FD stigma, such that future efforts can more effectively tackle the stigma of facial difference.

Impact of fixed-dose combination Cal/BD foam on the work productivity of patients with psoriasis: Results from the 52-week randomized, double-blind, PSO-LONG trial

BACKGROUND

Psoriasis contributes to unemployment, work impairment, missed workdays, and substantial indirect costs due to lost productivity. Combination Cal/BD foam is the only topical that is approved for long-term maintenance treatment of plaque psoriasis for 52 weeks. This is the first known investigation of the effect of a topical psoriasis therapy on productivity.

OBJECTIVE

To examine the change in work productivity and activity impairment after four weeks of treatment with fixed-dose combination calcipotriol 50 µg/g / betamethasone dipropionate 0.5 mg/g (Cal/BD) foam and observe long-term changes after 52 weeks of long-term management (proactive or reactive treatment).

METHODS

This is a post-hoc analysis of the PSO-LONG trial - a phase 3, randomized, double-blind, vehicle-controlled, parallel group, international multi-center trial of treatment with combination Cal/BD foam. Work and activity impairment due to psoriasis were assessed by the Dermatology Life Quality Index (DLQI) and the Work Productivity and Activity Impairment Psoriasis (WPAI:PSO) questionnaire at baseline, week 4, week 28 and week 56. The improvement in hours of work productivity was translated into monthly and annual indirect cost savings estimates for patients in Italy, Sweden, UK, Canada, and Germany.

RESULTS

Using fixed-dose combination Cal/BD foam for four weeks significantly reduced psoriasis-related work presenteeism, total work productivity impairment (TWPI) and total activity impairment (TAI) over 56 weeks, with significant improvements observed as early as four weeks after the baseline visit. The proportion of patients reporting impact on work productivity (as measured by presenteeism and TWPI) and activity impairment (as measured by both DLQI-Q7b and TAI) also decreased.

CONCLUSION

Fixed-dose combination Cal/BD foam used for long-term management of psoriasis significantly reduces psoriasis-related work productivity and activity impairment which may result in substantial indirect cost savings.

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.

Evaluation of Healthy Lifestyle Behaviors in Psoriasis Patients

Objectives

The purpose of our study was to compare healthy lifestyle behaviors between psoriasis patients and healthy controls.

Methods

This case-control study included 80 psoriasis patients and 80 sex- and age- matched healthy controls aged over 18. Participants completed the socio-demographic data form and the Health-Promoting Lifestyle Profile II (HPLP-II). The HPLP-II consists of 52 items and measures six components of health-promoting behavior outcomes: Nutrition, physical activity, health responsibility, spiritual growth, interpersonal relations, and stress management. Higher scores show that the individual applies the specified health behaviors at a high level.

Results

HPLP-II total scores were 128.3±21.1 in patient group and 132.5±22.3 in control group. Based on the scores, psoriasis patients showed a moderate level of health-promoting lifestyle, while controls showed a good level of health-promoting lifestyle. Spiritual growth score of patients (mean±SD = 25.6±4.9) was statistically lower than the controls (mean±SD = 27.3±4.5) (p=0.040). In addition, spiritual growth score and disease duration were negatively correlated in the patient group (r=-0.287, p=0.01). Furthermore, nutrition score of those with additional comorbidity was significantly higher than those with psoriasis alone in patient group (p=0.002).

Conclusion

This is the first study to compare healthy lifestyle behaviors of psoriasis patients and healthy volunteers in Turkish population. The task of dermatologists is not only the medical treatment of psoriasis lesions but also questioning patients' lifestyle behaviors and supporting the development of healthy behaviors in patients.

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.

The Validity of Cutaneous Body Image as a Construct and as a Mediator of the Relationship Between Cutaneous Disease and Mental Health

Introduction

Cutaneous body image (CBI) is a construct encompassing how individuals perceive their hair, skin, and nails. Negative CBI has been related to negative psychological outcomes and body image concerns. The first aim of our study was to further validate CBI as a construct. Second, as individuals with dermatologic conditions are at an increased risk for anxiety and depression, the study examined CBI as a mediator of the relationships between having a skin condition and anxiety and depression.

Methods

A convenience sample of clinical participants with dermatologist-validated diagnoses of psoriasis, atopic dermatitis, or acne who were currently taking systemic medication (n = 128) were matched to a sample of comparison participants without skin conditions (n = 128) on self-reported gender, ethnicity, developmental stage, and weight status (body mass index). All participants reported on their CBI, self-esteem (global, appearance-related, and weight-related), body dissatisfaction, drive for thinness, dietary restraint, anxiety, depression, and demographic characteristics.

Results

Cutaneous body image was more negative in those respondents with skin conditions (regression analysis B = − 0.61, standard error 0.23, p = 0.008), demonstrating the criterion-related validity of the measure. CBI was significantly correlated with global (r  = 0.39, p  < 0.001) and appearance-related self-esteem (r  = 0.50, p  < 0.001), which establishes convergent validity. CBI was not significantly related to a drive for thinness (r  = − 0.12, p  = 0.06) or to dietary restraint (r  = − 0.05, p  = 0.39), supporting discriminant validity. CBI mediated the relationships between having a dermatologic condition and anxiety [point estimate of indirect effect 0.07, 95% confidence interval (CI) 0.02, 0.15] and depression (point estimate of indirect effect 0.04, 95% CI 0.01, 0.08).

Conclusions

The measure of CBI has been further validated. Dermatologists must be aware that various dermatoses may impact patient mental health via the mechanism of negative CBI.

Electronic supplementary material

The online version of this article (10.1007/s13555-020-00351-5) contains supplementary material, which is available to authorized users.

Stigmatization in Arabic psoriatic patients in the United Arab Emirates - a cross sectional study

Introduction

Stigmatization is the phenomenon of labeling negatively people who differ from social norms in some aspect. It seems to be a common and important problem in dermatology. Psoriasis, being a chronic and recurrent skin disease, is frequently associated with various psychosocial consequences.

Aim

To evaluate the stigmatization level in an Arabic population of psoriatic individuals.

Material and methods

A total of 108 consecutive patients suffering from psoriasis were enrolled in the study. All recruited subjects were of Arabic origin. Severity of psoriasis was documented with the Psoriasis Area and Severity Index (PASI). Stigmatization was assessed with validated Arabic language versions of the 6-item Stigmatization Scale and the Feelings of Stigmatization Questionnaire. Moreover, all patients were asked to complete the Dermatology Life Quality Index (DLQI) questionnaire.

Results

The majority of patients showed feelings of stigmatization due to psoriasis. The mean level of stigmatization was 5.6 ±4.5 points assessed by the 6-item Stigmatization Scale and 98.4 ±26.4 points by the Feelings of Stigmatization Questionnaire. Positive attitudes and feeling of being flawed were the most bothersome aspects of stigmatization expressed by patients. Involvement of the face appeared to be the only independent factor influencing the stigmatization level. In the Feelings of Stigmatization Questionnaire, itching was found to be a factor responsible for feelings of stigmatization.

Conclusions

Our study indicated that stigmatization is common among psoriatic Arabic patients. We postulate that measurement of stigmatization level could contribute to the holistic therapeutic approach of psoriatic patients.

Translating the WHA resolution in a member state: towards a German programme on 'Destigmatization' for individuals with visible chronic skin diseases

BACKGROUND

Even today, a substantial number of individuals with visible skin diseases still suffer from incomprehension and stigmatization. About 10 million people are affected by such diseases in Germany. The WHO strongly urges member states to take measures against stigmatization in skin diseases.

OBJECTIVES

Objectives are the development of an action programme to raise awareness and address stigmatization. Therefore, conception, development and testing of interventions for the destigmatization of persons with skin diseases in Germany will be carried out.

METHODS

A series of actions addressing decision makers, politicians and the Federal Ministry of Health were initiated, all based on the World Health Assembly (WHA). Argumentation was largely based on data from health services research. Supported by the Federal Ministry of Health, a concept against stigmatization was developed by an expert consortium of researchers, dermatologists and patients. Specific strategies of structured destigmatization between those affected and those not will be developed and scientifically evaluated.

RESULTS

The activities addressed to politics were - to a large extent - successfully and financially supported by a 3-year programme (2018-2020), designed to develop interventions against stigma. It was funded by the Federal Ministry of Health. The project includes conception and development, intervention and evaluation, data analyses and development of a long-term concept.

CONCLUSIONS

The WHO's call against stigmatization in psoriasis (resolution WHA67.9 and global report on psoriasis 2016) was taken into account and developed into a destigmatization programme supported by the German government and German politicians. This has been achieved by successful collaborations between dermatologists, researchers, patients and policymakers. Next step will be the testing of interventions in situations and surroundings, where stigmatization usually occurs. The data will be used for the implementation of a long-term concept that can be used to continue destigmatization in Germany far beyond the project's initial phase.

Internalized stigma in psoriasis: A multicenter study

Internalized stigma is the adoption of negative attitudes and stereotypes of the society regarding a person's illness. It causes decreased self-esteem and life-satisfaction, increased depression and suicidality, and difficulty in coping with the illness. The primary aim of this study was to investigate the internalized stigma state of psoriatic patients and to identify the factors influencing internalized stigma. The secondary aim was to identify the correlation of internalized stigma with quality of life and perceived health status. This multicentre, cross-sectional study comprised 1485 patients. There was a significant positive correlation between mean values of Psoriasis Internalized Stigma Scale (PISS) and Psoriasis Area and Severity Index, Body Surface Area, Dermatological Life Quality Index and General Health Questionnaire-12 (P < 0.001 in all). Lower percieved health score (P = 0.001), early onset psoriasis (P = 0.016), family history of psoriasis (P = 0.0034), being illiterate (P < 0.001) and lower income level (P < 0.001) were determinants of high PISS scores. Mean PISS values were higher in erythrodermic and generalized pustular psoriasis. Involvement of scalp, face, hand, genitalia and finger nails as well as arthropathic and inverse psoriasis were also related to significantly higher PISS scores (P = 0.001). Our findings imply that psoriatic patients experience high levels of internalized stigma which are associated with psoriasis severity, involvement of visible body parts, genital area, folds or joints, poorer quality of life, negative perceptions of general health and psychological illnesses. Therefore, internalized stigma may be one of the major factors responsible from psychosocial burden of the disease.

Stigmatization, Physical Illness and Mental Health in Primary Ciliary Dyskinesia

Primary ciliary dyskinesia (PCD) causes chronic cough, sinusitis and bronchiectasis, and half of patients also show situs inversus. The genetic basis and visible and concealed chronic symptoms provide potential for stigmatization. We describe a structural equation model linking a questionnaire measure of stigmatization to sex, age, personality (Big Five), symptoms (St George’s Respiratory Questionnaire), health status (SF-36) and stress (GHQ-12). Stigma did not relate to physical symptoms or health, or to situs, but correlated with mental health and the social impact of symptoms. Neuroticism, extroversion, openness to experience, age, age at diagnosis and being female indirectly affected stigmatization via mental health.

Treatment of Dermatological Conditions Associated with HIV/AIDS: The Scarcity of Guidance on a Global Scale

Background. Skin diseases associated with Human Immunodeficiency Virus (HIV) infection are associated with significant morbidity and mortality. In resource-limited settings, nondermatologists and lay health care providers on the front line of HIV care provide much of the treatment for these conditions. Objective. To evaluate guidelines for treatment of HIV-related skin conditions and assess their accessibility, comprehensiveness, and quality of evidence employed. Methods. A review was undertaken of all national and society guidelines which included treatment information on the ten highest burden HIV-related skin conditions. The search strategy included gray and peer-reviewed literature. Results. Of 430 potential guidelines, 86 met inclusion criteria, and only 2 were written specifically to address HIV-related skin diseases as a whole. Treatment information for HIV-related skin conditions was embedded within guidelines written for other purposes, primarily HIV/AIDs treatment guidelines (49%). Development of guidelines relied either partially or completely on expert opinion (62%). Only 16% of guidelines used gradation of evidence quality and these were primarily from high-income countries (p = 0.001). Limitations. Due to the nature of gray literature, not all guidelines may have been identified. Conclusion. This review highlights the need for evidence-based summary guidelines that address treatment for HIV-related skin conditions in an accessible format.

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.

Quality of life and work productivity impairment among psoriasis patients: findings from the National Psoriasis Foundation survey data 2003-2011

Objective

To ascertain impairment in quality of life and work productivity among patients with psoriasis and psoriatic arthritis.

Design

From 2003 through 2011, the National Psoriasis Foundation collected survey data from patients with psoriasis and psoriatic arthritis via email and telephone correspondences.

Setting

Survey data were collected from psoriasis and psoriatic arthritis patients in the general community in the U.S.

Main Outcome Measures

Quality of life focusing on emotional impact (anger, frustration, helplessness, etc.) and physical impact (pain, pruritus, physical irritation, etc.); employment status.

Patients

The surveys were performed through random sampling of participants from a database of over 75,000 patients.

Results

From 2003 to 2011, 5,604 patients completed the surveys. Psoriasis and psoriatic arthritis affected overall emotional wellbeing in 88% of patients, and they interfered with enjoyment of life in 82%. Most patients reported experiencing anger (89%), frustration (89%), helplessness (87%), embarrassment (87%), and self-consciousness (89%). Many patients also actively concealed physical manifestations of their diseases (83%), and experienced pain (83%) and pruritus (93%) regularly. Of note, 12% of patients were unemployed, and 11% worked part-time. Among unemployed patients, 92% cited psoriasis and/or psoriatic arthritis as the sole reasons for not working. Among working patients, 49% missed work days regularly due to psoriasis. Compared to patients with mild psoriasis, patients with severe psoriasis have 1.8 times greater odds to be unemployed after adjusting for age and gender (Adjusted OR = 1.7, 95% CI 1.4–2.3).

Conclusion

Patients with psoriasis and psoriatic arthritis continue to experience significant impairment of quality of life and work productivity.

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.

Stress and quality of life in psoriasis: an update

Psoriasis is a chronic, relapsing, cutaneous condition with 1-2% prevalence in the general population. There are many factors involved in the induction and/or exacerbation of psoriasis of which stress is a well-known trigger factor in the appearance or exacerbation of psoriasis. Stress reaction in patients with psoriasis is probably mediated by the hypothalamic-pituitary-adrenal relationship with immunologic effects. Stress response involves increased levels of neuroendocrine hormones and autonomic neurotransmitters. Psychological stress or an abnormal response to stressors has been found to modify the evolution of skin disorders such as psoriasis. It can also have substantial psychological, and psychosocial impact on a patient's quality of life. Treatment regimens include stress-reduction strategies, such as biofeedback, meditation, yoga, and self-help approaches. This review focuses the relationship between psoriasis and stress, especially relating to psychosocial, psychological, and emotional stress aspects.

Teaching empathy to undergraduate medical students using a temporary tattoo simulating psoriasis

BACKGROUND

Psoriasis has a profound negative effect on quality of life that is often underappreciated by health care professionals and the public.

OBJECTIVE

We sought to assess the perception of the burden of psoriasis relative to other medical conditions in first-year medical students, and to determine if wearing a temporary tattoo simulating psoriasis during a teaching exercise would change their perceptions.

METHODS

Participants completed a questionnaire assessing their perception of the impact of psoriasis and other common medical conditions (visual analog scale). Participants then wore a temporary tattoo of a psoriatic lesion for 24 hours and completed the same questionnaire after this exercise.

RESULTS

Of 91 students approached, 61 completed the study. At baseline, psoriasis (mean = 23.6) and eczema (mean = 23.3) were perceived as having the lowest physical burden of diseases queried (P < .0001), whereas the mental impact of psoriasis was scored comparably with arthritis, heart disease, and diabetes (mean = 45.1-56.7), but lower than cancer (mean = 82.2) and depression (mean = 93.8). After the exercise, the perception of the impact of eczema (physical: mean = 37.3, P < .0001; mental: mean = 66.6, P = .0005) and psoriasis (physical: mean = 37.8, P = .0014; mental: mean = 68.6, P = .0293) was significantly increased.

LIMITATIONS

The exercise did not simulate the chronic nature of psoriasis or the scaling and pruritic characteristics of psoriatic lesions. The survey instrument used to assess empathy has not been previously validated and statistical analysis was limited by small sample size and the absence of a control group.

CONCLUSIONS

Temporary tattoos are a novel and effective method of teaching medical students about the psychological burden of psoriasis.

Burden of skin diseases

Skin diseases are among the most common health problems worldwide and are associated with a considerable burden. The burden of skin disease is a multidimensional concept that encompasses psychological, social and financial consequences of the skin disease on the patients, their families and on society. Chronic and incurable skin diseases, such as psoriasis and eczema, are associated with significant morbidity in the form of physical discomfort and impairment of patients' quality of life; whereas malignant diseases, such as malignant melanoma, carry substantial mortality. With the availability of a wide range of health status and quality-of-life measures, the effects of most skin diseases on patients' lives can be measured efficiently. The aim of this review is to present some of the published data in order to highlight the magnitude of the burden associated with some common skin diseases and also to suggest ways to quantify this burden of skin disease.

Depression and quality of life in psoriasis

Psoriasis is a chronic inflammatory hyperproliferative disease of the skin, scalp, nails, and joints. The physical symptoms of psoriasis include itching, irritation, burning/stinging, sensitivity, and pain. Patients also suffer psychological distress, especially as a result of stigmatization, self-consciousness, and embarrassment, which can in turn affect employment and social activities. Relatively high rates of depression are reported in patients with psoriasis. Inflammatory cytokines such as tumor necrosis factor alpha, interferon gamma, and other type 1 cytokines play an important role in the pathogenesis and comorbidities of psoriasis. Data from both animal and human studies suggest that these cytokines are linked to depression. Some psoriasis treatments have demonstrated improvements in symptoms of psoriasis as well as in measures of depression and health-related quality of life. Physicians managing patients with psoriasis must be aware of the psychological effects of psoriasis and need to use a multifaceted approach to managing this disease, focusing on both the physical and psychological aspects.

Qualidade de vida e localização da lesão em pacientes dermatológicos

FUNDAMENTOS - O aspecto visível das lesões de pele e seu impacto psicológico interferem na qualidade de vida dos pacientes. OBJETIVOS - Avaliar qualidade de vida e localização da lesão dermatológica, verificar associação entre variáveis e comparar níveis de qualidade de vida em pacientes com lesões na face/ou mãos e pacientes somente com lesões em outras regiões do corpo que não face e/ou mãos. MÉTODO - Estudo transversal, descritivo, de ssociação. Foram avaliados 205 sujeitos através do Questionário Genérico de Qualidade de Vida- SF-36 "The Medical Outcomes Study 36-item Short-Form Health Survey" (SF-36) e do Dermatology Life quality Index, fichas de dados sócio-demográficos e de localização da lesão. RESULTADOS - Não foram observadas diferenças significativas na qualidade de vida entre os dois grupos, mas o número de associações entre SF-36 e DLQI-BRA foi superior no grupo com lesões em face e/ou mãos. Diferenças significativas foram verificadas quando da divisão em cinco grupos. A diferença significativa (p=0,05) foi entre o grupo com lesões somente em face e/ou mãos e o grupo com lesões generalizadas, sendo que este último teve posto médio de 114,06 contra 69,1935 do outro grupo. CONCLUSÕES - Independente da localização da lesão, o sentimento de exposição e os prejuízos a que fica sujeito o paciente dermatológico são semelhantes. As doenças da pele, ao que parece, provocam sentimento de exposição e constrangimento, independente do local do corpo acometido, pois na aproximação mais íntima de outra pessoa está implicada certa exposição.

Localização da lesão e níveis de stress em pacientes dermatológicos

O stress repercute nas doenças de pele. A pele é um órgão visível, que tem importância nas relações interpessoais e pode trazer prejuízos quando lesionada. Neste estudo, avaliou-se stress e localização da lesão dermatológica e a associação entre essas variáveis, comparando níveis de stress em pacientes com lesões no rosto e/ou mãos e pacientes com lesões em outras partes do corpo. Tratou-se de um estudo transversal, descritivo, de associação. Participaram 205 pacientes, que responderam ao Inventário de Sintomas de Stress para Adultos de Lipp, às Fichas de Dados Sócio-Demográficos e de Localização da Lesão. Quanto aos resultados, houve presença de sintomas de stress na maioria dos pacientes; a fase de resistência e a sintomatologia psicológica foram predominantes. Na comparação entre grupos com diferentes localizações de lesão, não houve diferenças significativas quanto aos resultados de stress (p=0,495; p=0,873 e p=0,815). Os achados corroboram a necessidade de um atendimento biopsicossocial aos pacientes.

Gender differences in skin: a review of the literature

BACKGROUND

There has been increasing interest in studying gender differences in skin to learn more about disease pathogenesis and to discover more effective treatments. Recent advances have been made in our understanding of these differences in skin histology, physiology, and immunology, and they have implications for diseases such as acne, eczema, alopecia, skin cancer, wound healing, and rheumatologic diseases with skin manifestations.

OBJECTIVE

This article reviews advances in our understanding of gender differences in skin.

METHODS

Using the PubMed database, broad searches for topics, with search terms such as gender differences in skin and sex differences in skin, as well as targeted searches for gender differences in specific dermatologic diseases, such as gender differences in melanoma, were performed. Additional articles were identified from cited references. Articles reporting gender differences in the following areas were reviewed: acne, skin cancer, wound healing, immunology, hair/alopecia, histology and skin physiology, disease-specific gender differences, and psychological responses to disease burden.

RESULTS

A recurring theme encountered in many of the articles reviewed referred to a delicate balance between normal and pathogenic conditions. This theme is highlighted by the complex interplay between estrogens and androgens in men and women, and how changes and adaptations with aging affect the disease process. Sex steroids modulate epidermal and dermal thickness as well as immune system function, and changes in these hormonal levels with aging and/or disease processes alter skin surface pH, quality of wound healing, and propensity to develop autoimmune disease, thereby significantly influencing potential for infection and other disease states. Gender differences in alopecia, acne, and skin cancers also distinguish hormonal interactions as a major target for which more research is needed to translate current findings to clinically significant diagnostic and therapeutic applications.

CONCLUSIONS

The published findings on gender differences in skin yielded many advances in our understanding of cancer, immunology, psychology, skin histology, and specific dermatologic diseases. These advances will enable us to learn more about disease pathogenesis, with the goal of offering better treatments. Although gender differences can help us to individually tailor clinical management of disease processes, it is important to remember that a patient's sex should not radically alter diagnostic or therapeutic efforts until clinically significant differences between males and females arise from these findings. Because many of the results reviewed did not originate from randomized controlled clinical trials, it is difficult to generalize the data to the general population. However, the pressing need for additional research in these areas becomes exceedingly clear, and there is already a strong foundation on which to base future investigations.

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

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

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

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

Living with primary ciliary dyskinesia: a prospective qualitative study of knowledge sharing, symptom concealment, embarrassment, mistrust, and stigma

BACKGROUND

Primary ciliary dyskinesia (PCD) is a chronic respiratory disease for which there is little psycho-social research and no qualitative studies of individuals living with the condition. A questionnaire-based survey in 2003 found evidence of stigmatisation in some individuals with PCD. Although the questionnaire had face and construct validity, stigmatisation was not cross-validated against interviews. The present study had the twin aims of carrying out a qualitative study of the adult patients living with PCD, and using a structured design to validate the questionnaire measure of stigma.

METHODS

Interviews were carried out with six pairs of individuals with PCD, matched for sex, situs, and age, one with a high stigma score in 2003 and the other with a low stigma score. Depth-qualitative interviews were conducted by one author to explore themes surrounding the psycho-social impact of PCD using a grounded theory analysis. The interviewer was blind to the stigma scores of participants, and after the qualitative analysis was completed, the interviewer made an assessment of which member of each pair seemed the more stigmatised, after which the code was broken.

RESULTS

Interviews revealed a number of themes, including other people's knowledge of PCD, the sharing of knowledge about PCD, the concealment of symptoms of PCD, embarrassment at symptoms, changes of behaviour in response to PCD, mistrust of medical care, in particular in relation to problems in diagnosis, a mistrust of general practitioners who were seen as poorly informed, and the importance of expert care at tertiary referral centres. Although stigmatisation as such was rarely mentioned directly by respondents, when the interviewer's judgement on level of stigmatisation was correlated with stigma scores from 2003, it was found that the more stigmatised member had been correctly identified in all six pairs (p = .016).

CONCLUSION

Our results suggest that some people with PCD feel isolated through mistrust in medicine, and lack of knowledge surrounding PCD. Many responses to PCD can be explained in terms of stigmatisation, and in particular felt stigma. The correlation between questionnaire used several years previously, and the interviewer's judgements of stigmatisation suggest that the stigma questionnaire had both predictive validity and long-term stability. As in other chronic conditions, stigmatisation occurs only in some individuals with PCD, and the present study explores the basis of stigmatisation, and validate the questionnaire as a measure of difference in stigma.

Psychologic Factors in Psoriasis: Consequences, Mechanisms, and Interventions

The article examines the English-language research literature concerning psychologic aspects of psoriasis published since 1995. The literature is concerned with (1) the consequences of psoriasis in terms of quality of life, disability, depression, anxiety, and stigmatization and factors that may predict such outcomes; (2) potential mechanisms of the interaction between psychologic factors, stress, and the pathophysiology of psoriasis; and (3) examination of the clinical utility of psychologic interventions on extent of psoriasis and psychologic distress. The implications of the findings are discussed with reference to future directions for research and practice.

Does visible atopic dermatitis affect quality of life more in women than in men?

BACKGROUND

Studies have suggested that women overreport symptoms in nondermatologic disease. Gender-dependent differences in patients' perception of dermatologic disease are poorly described. The description of possible gender differences in morbidity in a skin disease with comparable prevalence in men and women may therefore provide relevant data.

OBJECTIVE

The goal of this study was to examine gender-dependent differences in the self-reported morbidity of patients with atopic dermatitis (AD).

METHODS

Questionnaires from members of the Atopisk Eksem Forening (Danish Association of Atopic Eczema) aged > or = 15 years were analyzed. Data were gathered regarding age, sex, disease duration and severity, and localization of AD, including the results of the Dermatology Life Quality Index (DLQI), a quality-of-life questionnaire designed for use in adults (ie, patients aged > or = 15 years).

RESULTS

Questionnaires from 112 patients were analyzed. The final study population comprised 88 females and 24 males; mean age was 35.3 years (range, 15-77 years). For women, a significant positive correlation was found between DLQI score and disease severity (P < 0.001) and also between DLQI score and visible regions affected by disease (P = 0.001); these correlations were not observed in men. For the total number of body regions affected, a significant correlation with severity was found for women (P = 0.001) but not for men. No significant differences between men and women were noted for age, disease duration, overall disease severity, or quality of life as assessed using the DLQI.

CONCLUSION

Self-reported morbidity is highly consistent among women with AD, but not so among men. Normally visible areas of AD appear to affect women significantly more than men.

Involving the patient: Impact of inflammatory skin disease and patient-focused care

Atopic dermatitis (AD) and psoriasis are common chronic inflammatory diseases that are associated with significant psychosocial morbidity and a decrease in health-related quality of life (QOL). To better understand the effects of these two diseases on quality of life, as reported in the literature, a review of all English-language articles from 1970 to 2003 was performed using PubMed. Results from these studies and surveys illustrate the profound negative impact exerted by these conditions and the importance of early and appropriate treatment. These concerns can be incorporated into patient management strategies that focus on a new model for healthcare delivery, "patient-centered care," in which QOL plays an integral role. The impact of AD and psoriasis on physical, social, psychological, and financial aspects of life should not be trivialized and must be considered with the same importance as other chronic conditions. Because psoriasis and AD are chronic conditions that require patient and/or caregiver involvement for optimal management, the concept of patient-centered care with its emphasis on effective two-way communication is particularly important and useful for the clinician.

The psychosocial burden of psoriasis

BACKGROUND

Skin diseases such as psoriasis can profoundly influence a patient's self-image, self-esteem, and sense of well-being. Psoriasis is a multifactorial inflammatory condition with a disease burden that extends beyond the physical symptoms experienced by patients. Psoriasis affects all aspects of quality of life, including physical, psychologic, social, sexual, and occupational elements.

OBJECTIVE

The goal of this article was to review the published literature on the impact of psoriasis on quality of life.

METHODS

Relevant studies were identified through a comprehensive search of MEDLINE, EMBASE, and the Derwent Drug File databases of English-language articles published between 1993 and 2005 using the terms psoriasis in combination with quality of life, cost, cost-benefit analysis, economic, employment, days lost, healthcare, hospitalization, managed care, outcomes research, occupation, payers, and psychosocial. The reference lists of identified articles were checked for additional studies that might have been missed in the original searches.

RESULTS

Data suggest that social stigmatization, high stress levels, physical limitations, depression, employment problems and other psychosocial co-morbidities experienced by patients with psoriasis are not always proportional to, or predicted by, other measurements of disease severity such as body surface area involvement or plaque severity.

CONCLUSION

It is essential to include measures of psychosocial morbidity when assessing psoriasis severity and treatment efficacy because of the substantial role that psychosocial burden plays in patient perception of disease severity, quality of life, and disease course.

The impact of psychological and clinical factors on quality of life in individuals with atopic dermatitis

OBJECTIVE

The aim of the study was to assess the influence of general and dermatitis-specific psychological and clinical factors on quality of life in adults with atopic dermatitis (AD).

METHOD

A total of 125 adults recruited through the National Eczema Society of U.K. (NES) completed a number of psychological and dermatological questionnaires, including the Dermatology Life Quality Index (DLQI), the Stigmatisation and Eczema Questionnaire (SEQ), the Hospital Anxiety and Depression Scale (HADS), the Fear of Negative Evaluation Scale (FNE) and the Rosenberg Self-Esteem Scale (RSE).

RESULTS

Pearson's correlational analyses suggested that perceptions of stigma were significantly associated with psychological factors as well as quality of life (Ps<.01). An association was also found between perceived stigma and disease severity (-.28, P<.01). Almost 46% of participants were identified as having probable mood disorder. Regression analysis indicated that perceptions of stigma and depression accounted for 44.5% of the variance in quality of life in this sample [F(3,121)=34.18, P<.001], when disease severity was controlled for.

CONCLUSION

Psychological factors and disease severity were strong predictors of quality of life in adults with AD. AD-related perceptions of stigma were of particular importance in predicting AD-related quality of life over and above more general psychological factors, such as depression. These findings have important implications for the psychological and clinical management of AD.

Quality of life issues in psoriasis

Psoriasis is associated with significant psychosocial morbidity and a decrease in health-related quality of life. It is important to view psoriasis as a serious disease and resist the tendency to underestimate its impact on overall patient well-being. The disability experienced by psoriasis sufferers is comparable to that of patients with other chronic illnesses such as heart disease, diabetes, cancer, and depression. Aggressive intervention is warranted in order to improve patient quality of life and decrease the potential for psychosocial sequelae. Health-related quality of life measures are becoming a necessary adjunct to traditional clinical assessments in the evaluation and treatment of psoriasis patients by the individual clinician. They also provide valuable information to government agencies and third party payers in the determination of resource allocation and reimbursement.

Experiences of stigmatization play a role in mediating the impact of disease severity on quality of life in psoriasis patients

BACKGROUND

Psoriasis may have a severe impact on patients' quality of life (QOL) in several ways, an impact mediated by the mental or physical difficulties they have to deal with during the course of the disease and the various treatment regimens. In addition, psoriatic patients often suffer from experiences of stigmatization (EOS) related to the disease.

OBJECTIVES

This study was designed to test the hypotheses that psoriasis patients report higher levels of stigmatization than a comparison group, and that their EOS play a role in mediating the impact of the severity of psoriasis on their QOL.

METHODS

One hundred patients with psoriasis (study group) and 100 patients with mixed skin problems (comparison group) were matched according to age, sex and education. All subjects answered questionnaires on EOS and QOL. A dermatologist diagnosed the diseases and measured severity scores. The Psoriasis Area and Severity Index score was used for psoriasis and a linear severity score for the comparison patients. The mediating effect of EOS was analysed using structural equation modelling (SEM). SEM is a multivariate statistical method used to examine the consistency of a theory relating one group of variables (termed a 'latent construct') to another: in the present study, the relationship between EOS and QOL.

RESULTS

Psoriatic patients were found to report significantly higher levels of EOS related to the disease, compared with the comparison group. No significant differences were found regarding QOL or severity of disease. Clinical severity of psoriasis was found to correlate negatively with QOL in psoriasis patients. EOS were found to have a complete mediating effect for the severity of disease on the QOL in patients with psoriasis. This result was not found among the comparison group patients.

CONCLUSIONS

The results of this study indicate that psoriasis patients experience higher levels of stigmatization than do other dermatological patients, and that these EOS mediate the association between disease severity and patients' reported low levels of QOL. Treatment of psoriatic patients should consider these results and should include tools for psychosocial intervention.

Sex-specific differences in the treatment of severe psoriasis

BACKGROUND

Psoriasis treatment requires consideration of patient-specific concerns in addition to the severity of skin involvement. There may be sex-specific differences in the treatment of severe psoriasis.

OBJECTIVE

The purpose of this study was to determine whether there are sex-specific differences in the treatment of severe psoriasis.

METHODS

We analyzed the medications prescribed to patients with a primary and only diagnosis of psoriasis recorded in the 1990-1994 National Ambulatory Medical Care Survey.

RESULTS

There were 8.5 million visits to physicians for the treatment of psoriasis in the years 1990-1994. These visits were made by approximately 4.3 million women and 4.1 million men. Only 39% of patients receiving systemic treatments were women. Women received less methotrexate (23% women) and etretinate (35% women) than men, but more psoralen photochemotherapy (PUVA) (63% women) and isotretinoin (100% women) than men. In contrast, there was no notable difference by sex in the potency of topical corticosteroid agents prescribed.

CONCLUSION

For mild disease treated with topical agents alone, there is no notable difference in the treatment of men and women. Men are more likely than women to receive intensive treatments for severe psoriasis, at least in part because of the teratogenic potential of these treatments. There is a need for development of new treatments for severe psoriasis that are safe for women of childbearing potential.

What patients with psoriasis believe about their condition

BACKGROUND

Patients' beliefs about their disease have been shown to be of fundamental importance in adjustment to their condition.

OBJECTIVE

We investigated patients' beliefs about their psoriasis and examined the relationship between these beliefs and clinical severity, symptom report, and other clinical and demographic variables.

METHODS

A total of 162 patients with psoriasis (84 male, 78 female) completed the illness perception questionnaire that provides a standardized assessment of beliefs about causes, consequences, chronicity or recurrence, controllability, and symptoms of the condition.

RESULTS

The most commonly reported agents of causation were stress (60.1%) and genetic factors (55.5%)--the latter group being significantly more likely to have a family history of psoriasis (P=.0001). Forty-six percent of patients believed that their behavior could improve or worsen their psoriasis, whereas 32% believed that treatment would be curative. Desquamation and pruritus were experienced "frequently" or "all the time" by 80% and 76% of patients respectively. Overall clinical severity was not associated with any of the beliefs held by patients or with symptom report.

CONCLUSION

The beliefs held and symptoms experienced by patients with psoriasis are not governed by overall clinical severity of the disease.