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Background: Psoriasis is a complex, chronic, lifelong inflammatory skin disease characterized by the development of erythematous, indurated, scaly, pruritic, and often painful skin plaques, and it is currently incurable. It profoundly affects psychological wellbeing and social functioning and has significant associated co-morbidities. To improve clinical approaches, understanding of the experiences of patients with psoriasis is needed., Objective: To explore the experiences and coping behaviors of patients with psoriasis., Methods: A qualitative study approach was conducted. Through semi-structured interviews, 20 patients with psoriasis were recruited from general practices and specialist dermatology practices in a regional teaching hospital in Taiwan. Recorded interviews were transcribed and analyzed by content analysis., Results: Three themes and nine subthemes were identified: (1) Symptoms distress: (a) trouble with scaling, (b) bothersome itching, and (c) complex pain experiences; (2) Psychological distress: (a) encountering discrimination and (b) feeling stigmatized; (3) Managing psoriasis: (a) coping with symptoms, (b) seeking alternative methods, (c) using biologic agents, and (d) changing thinking and coexisting with the disease., Conclusion: The experience of patients with psoriasis has significant negative impacts on their lives. The findings of this study can provide healthcare professionals with a reference for the care of patients with psoriasis.

Background: Treatment needs of young psoriasis patients and parents are not widely studied and could advance patient-centered care., Objective: To explore treatment goals and preferences of pediatric psoriasis patients, young adults, and parents., Methods: A web-based survey among Dutch psoriasis patients aged ≥6 to ≤30 years and parents included multiple-choice, open-ended, and 4-point Likert scale questions. Treatment goals and characteristic preferences of pediatric patients (≤17 years) were compared to young adults (≥18 years) and parents., Results: 195 young patients (20.2 ± 6.3 years) and 45 parents were included. The most important treatment goals were 'preventing lesions', 'reducing lesions', 'no itch', and 'no lesions'. Regarding treatment characteristics, 'long-term safety', 'high effectiveness', and 'short-term safety' were most important. We found differences by age, gender, and current treatment. Pediatric patients rated 'not sticky', 'quick results', and 'no/few blood samples needed' higher than parents and/or young adults. Young adults rated 'feeling more confident' and 'better quality of sleep' higher than pediatric patients. Parents considered safety most important. Psychosocial goals were more important for women and patients on biologics., Conclusion: Young psoriasis patients and parents mainly strive to clear lesions and itch with effective and safe treatment. However, revealed differences underline the relevance of addressing individual needs.

Objectives: To describe ixekizumab treatment patterns, all-cause healthcare utilization, and costs among psoriasis patients. Methods: Adults diagnosed with psoriasis having ≥1 ixekizumab claim were selected from MarketScan ® databases between March 01, 2016 and July 31, 2017. Patients were continuously enrolled for ≥6 months prior and ≥3 months after the index date (first ixekizumab claim) and followed until inpatient death, end of enrollment, or end of data. Treatment patterns included persistence, switching, and re-initiation. All-cause utilization and costs were reported per-patient-per-month (PPPM). Results: 801 patients (mean age 49 years; 55.8% male; median follow-up 201 days) were included. Among all patients, 87.4% were persistent (mean (median) duration 86 (75) days) Of the 12.6% of patients who discontinued ixekizumab, 11.9% re-initiated and 6.9% switched treatments. Mean (median) time to switching was 208 (206) days. Mean number of all-cause inpatient admissions and physician office visits PPPM were 0.01 and 0.72, respectively. Mean total cost PPPM was $8,371, of which pharmacy comprised $7,792. Ixekizumab costs, $7,079, occurred primarily during induction and were paid predominantly by health plans ($6,810 [96.2%]). Conclusion: Most (87.4%) ixekizumab users remained persistent during follow-up. Pharmacy was the primary driver of total healthcare costs, with the majority covered by health plans and <4% as patient out-of-pocket expense.

Background: Many patients with psoriasis struggle with taking biologic agents. The way in which providers present medications could enhance treatment adherence. Objectives: To determine how fear appeals, personal appeals, and social appeals influence psoriasis patients' willingness to use a biologic. Methods: A randomized online survey study was used to assess subjects with a self-reported diagnosis of psoriasis and their willingness to initiate treatment. Subjects were randomized in a 1:1:1 ratio to receive an online survey with the following emotional appeals: social, fear, or personal ( n  = 315). Subject-reported willingness to take treatment was recorded on a 10-point Likert scale and analyzed via single-factor ANOVA, two-group t-tests, chi-squared analysis, and multiple linear regression analysis. Results: A total of 315 subjects with a reported diagnosis of psoriasis completed the survey. Patient demographic information includes the following: mean age of 35 years ± 11.2; 67% female. Compared to subjects presented with a social appeal ( M  = 6.2, SD = 2.9), subjects presented with a fear appeal ( M  = 7.1, SD = 2.5, p  = .01) and personal appeal ( M  = 7.0, SD = 2.7, p  = .03) reported a greater average willingness to take treatment. Conclusions: Presenting biologic agents using fear or personal appeals may be a simple and effective technique to improve patients' willingness to take treatment.

Psoriasis can adversely affect quality of life (QoL) and emotional well-being. In this UK prospective observational study we evaluated the 'real-world' impact of adalimumab on QoL and the physical/psychological effects of moderate-to-severe psoriasis. Hundred and forty-three biologic-naïve patients with moderate-to-severe psoriasis, receiving adalimumab in clinical practice, were included. Patients completed a series of questionnaires at baseline (adalimumab initiation), 4 and 16-weeks and 6-months post-adalimumab initiation during routine visits. The main outcome measure was the proportion of Dermatology Life Quality Index (DLQI) 'responders' at 16 weeks, defined as ≥5 point reduction from baseline or DLQI = 0.90% (95% CI = 80.8%-94.6%) of evaluable patients were DLQI responders at 16-weeks. There were significant improvements at 16 weeks in patient-reported measures of QoL, mental and physical well-being, cutaneous body image, anxiety, depression and psoriasis severity, which were maintained at 6-months. Adalimumab treatment was associated with improvements in patients' QoL and psychological functioning, which occurred contemporaneously with improvements in cutaneous disease.

Background: Psoriasis is a chronic inflammatory skin disorder with marked impact on quality of life. In view of the well-recognized need to integrate the patient perspective in psoriasis care, treatment goals which originate entirely from the experiences of the patients are of utmost importance. Objective: To explore treatment goals in patients with psoriasis that originate entirely from the patient perspective. Methods: Data was generated using face-to-face in-depth interviews with 15 Dutch psoriasis patients, which were analyzed using template analysis resulting in 2 first-level, 10 second-level, and 14 third-level themes. Results: A wide variety of treatment goals was reported. Almost all patients reported their 'ultimate' treatment goal would be achieving total skin clearance. Barriers in achieving treatment goals included the fact that psoriasis is a chronic disease with no cure available, lack of effectiveness of current treatment options and side effects of treatments of which the treatment effect does not compensate. Conclusion: There is a great variety and inter-individual difference in treatment goals. Therefore, we recommend to define individualized patient-defined treatment goals, as every patient with psoriasis requires a tailor-made treatment program.

Introduction: Thiazolidinediones have shown a good therapeutic effect in psoriasis treatment with no major adverse effects. The purpose of this study was to evaluate and compare the therapeutic effects of the combination of phototherapy and Pioglitazone with the phototherapy alone on plaque psoriasis patients. Methods and Materials: About 60 adults with plaque type psoriasis entered the study. They were randomly divided into two groups; one with pioglitazone and one with placebo and both underwent 30 sessions of phototherapy during 10 weeks. Before and after the treatment Psoriasis Area and Severity Index (PASI) and Dermatology Life Quality Index (DLQI) were assessed. Side effects of the treatment were also investigated. Results: The average PASI of the pioglitazone group was reduced from 20.9 ± 9.8 to 1.8 ± 1.4 ( p  < .001) versus the placebo group in which the PASI was reduced from 22 ± 8.5 to 4.4 ± 4. In other words, PASI was reduced in the pioglitazone and placebo group by 83.5% and 56.7% respectively ( p  < .05). The two groups didn't have a significant difference in reducing the DLQI ( p  = .315). Conclusion: Pioglitazone can vastly enhance the effectiveness of phototherapy in plaque psoriasis patients without causing any important adverse effect and with no success in improving the score of DLQI.

Background: Psoriasis can have a substantial impact on health-related quality of life (HRQoL), life course, and work productivity. Young adulthood is a critical, sensitive period of development that includes major life changing decisions. The impact of psoriasis on this vulnerable population is yet unknown., Objectives: To assess QoL, life course, and work productivity in young adults with psoriasis and identify characteristics influencing these patient-reported outcomes (PRO)., Methods: An explorative, cross-sectional study was performed in psoriasis patients aged 18-30 years. Individuals completed a set of questionnaires regarding their health status (DLQI, SF-36, EQ-5D), achievement of developmental milestones (COLQ), and work productivity (WPAI-PSO, PRODISQ)., Results: Seventy-five patients (22 males, 53 females; median age [IQR], 21.0 [8.0]). Median PASI and BSA, respectively, were 4.4 [4.9] and 4.5 [8.4]. Young adults experienced feelings of embarrassment, impairments in physical health and work productivity, and difficulties in social development. Patients with more severe psoriasis, longer disease duration, higher body mass index (BMI), female patients and patients closer to their thirties tended to be more affected., Conclusion: In the young adult psoriasis population, substantial QoL impairments were found. Female patients, patients with high BMI, or long disease duration in particular tended to experience more difficulties. These exploratory findings indicate the need for further studies in young adults to detect potential clinical predictors for severe HRQoL impairments.

Background: Psychiatric disorders are thought to play an important role in the onset, exacerbation and course of several chronic dermatological diseases. We aimed to investigate psychiatric diagnoses in children with psoriasis before and during the disease and to examine potentially related factors., Methods: A total of 108 children aged 8-16 years, 54 with a diagnosis of psoriasis and 54 healthy individuals, were included in the study. Participants were evaluated using The Kiddie Schedule for Affective Disorders and Schizophrenia, Present and Lifetime Version (K-SADS PL), Children's Dermatology Life Quality Index (CDLQI), Screen for Child Anxiety Related Emotional Disorders (SCARED) and Children's Depression Inventory (CDI), and the results were compared using statistical techniques., Results: At least one psychiatric diagnosis was present in 70.3% of children with psoriasis and in 27.7% of the control group, the difference being significant (p = .0001). It was seen that 73.6% of children with a psychiatric diagnosis were psychiatric diagnoses in the premorbid period. Children with psoriasis were determined to have 9.21-fold greater risk of anxiety (p = .0001) and a 6.65-fold greater risk of depression (p = .0019) compared with the control group., Conclusions: A statistically significant increase in psychiatric disorders occurs in disease periods in cases of pediatric psoriasis. Moreover, a high prevalence of psychiatric disorders was detected in the premorbid process. We think that it is important for these to be considered in the management of the disease and in controlling exacerbation, and for the mechanisms involved to be elucidated.

Purpose: We sought to compare the impact of biologic versus oral therapies on mental health outcomes among adult U.S. residents with moderate-to-severe psoriasis., Methods: We performed a nationwide, cross-sectional study comparing 2,303,534 (weighted) adults with moderate-to-severe psoriasis on biologic versus oral therapies and their associated mental health outcomes using the 2003-2015 Medical Expenditure Panel Survey (MEPS). Mental health outcomes were measured with the Kessler 6 (K6), a validated measure of psychological distress, and Patient Health Questionnaire 2 (PHQ2), a screening tool for depression., Results: The mean K6 score for residents on biologic therapies was significantly lower than that of residents on oral therapies (2.72 [95% CI: 2.27-3.17] versus 3.70 [95% CI: 3.27-4.12]; p < .001). The mean PHQ2 score for residents on biologic therapies was also significantly lower than that of residents on oral therapies (0.540 [95% CI: 0.390-0.690] versus 0.890 [95% CI: 0.749-1.031]; p < .001). Based on adjusted multivariable linear regression models, biologic therapy was associated with significant reductions in K6 (p < .001) and PHQ2 (p = .016) scores compared to oral therapy., Conclusions: Therapeutic choices for psoriasis impact mental health outcomes. Biologic therapy is associated with reductions in psychological distress and depression as compared to oral therapy in the U.S. adult moderate-to-severe psoriasis population.

Purpose: Data on chronic plaque psoriasis severity and its potential clinical and lifestyle implications in the Brazilian population are limited. The primary aim of this study was to assess the clinical severity of plaque psoriasis in Brazil. Further objectives included evaluating potential associations between disease severity and demographic, lifestyle, and clinical characteristics, health-related quality of life (HRQOL), and work productivity., Materials and Methods: This observational (non-interventional) cross-sectional study was conducted in 26 dermatologic clinics across 11 Brazilian states. Psoriasis severity was assessed using investigator judgment and Finlay's Rule of Tens: a Psoriasis Area and Severity Index (PASI) score >10, a Body Surface Area (BSA) > 10%, or a Dermatology Life Quality Index (DLQI) score >10., Results: Among 1125 patients, 205 (18.2%) had moderate-to-severe disease. On multiple regression analyses, psoriasis severity was significantly (directly) associated with the presence of physical inactivity and comorbid pain, anxiety, and depression; and significantly (inversely) associated with HRQOL and work productivity., Limitations: Cross-sectional studies cannot assess temporal trends, and observational studies cannot conclusively determine causality or exclude biases and confounding due to unmeasured variables., Conclusions: Among Brazilian patients with moderate-to-severe psoriasis, disease severity had far-reaching adverse impacts on lifestyle, comorbidities, HRQOL, and work productivity.

Background: Psoriasis is a chronic skin disease associated with psychiatric co-morbidities, especially depression. Early detection of psychological vulnerability in patients with psoriasis seems to be of great clinical importance and significantly impacts the quality of life of the patients., Objectives: We sought to clarify the association between psoriasis and depressive symptoms in patients with moderate-to-severe psoriasis, and to determine the risk factors for depressive symptoms and analyze the effect of ustekinumab on the symptoms. We also aimed to evaluate the changes in glucose metabolism using 18 fluorodeoxyglucose (FDG) positron emission tomography (FDG-PET)., Methods: Fifteen patients with moderate-to-severe psoriasis scheduled to be treated with ustekinumab were enrolled. At baseline and after achieving a 75% reduction in the Psoriasis Area and Severity Index (PASI) score (PASI75), all patients underwent a psychiatric interview and FDG-PET. Fifteen healthy volunteers were enrolled for comparison., Results: Patients with moderate-to-severe psoriasis were more depressed than those in the control group were (p < .05). The severity of psoriasis at baseline did not correlate with the depression symptoms. Treatment with ustekinumab significantly reduced the depressive symptoms, as verified using Beck Depression Inventory and Hamilton Depression Rating Scale psychiatric interviews (p < .05). However, FDG-PET of the brain showed no significant difference before and after PASI75 achievement using ustekinumab injection., Conclusions: Patients with moderate-to-severe psoriasis are at an increased risk for depressive symptoms, and treatment with ustekinumab may be beneficial. FDG-PET does not reflect the changes in depressive symptoms in such patients.

Purpose: The primary aim of this study was to evaluate the readability, understandability, suitability and actionability of online psoriasis patient educational materials. A secondary aim was to identify areas for improvement., Materials and Methods: We conducted an evaluation study to assess online psoriasis patient educational materials from the American Academy of Dermatology and National Psoriasis Foundation available in July 2017. We used two validated assessment tools specific to online healthcare materials. Outcomes were expressed as percentages, where higher percentages corresponded to higher quality materials., Results: Overall, the educational materials had a mean understandability score (72.7%) that was understandable; a suitability score (58.8%) that was adequate; a reading grade level (10.5) that was not readable; and an actionability score (54.7%) that was not actionable. Areas of improvement include reading grade level, visual aids, word choice, specific steps for actions and cultural appropriateness., Conclusions: Online psoriasis patient educational materials are understandable and suitable, but they are written above the American Medical Association and National Institutes of Health's recommended 6th-8th grade reading level and are not actionable. Materials can benefit from decreasing reading grade level, including more visual elements, incorporating more actionable items and being culturally inclusive.

Background: Poor adherence to topical therapy, defined as the degree to which patients use medication as prescribed by their healthcare provider, represents a frequent cause of poor treatment outcomes., Objective: To evaluate the impact of individualized medication training on efficacy, adherence and patient satisfaction to 4 weeks of a topical therapy in psoriasis., Methods: All enrolled psoriatic patients were given a prescription for calcipotriol/betamethasone dipropionate gel once daily and were randomly assigned to one of the two following groups with a 1:1 allocation ratio. Patients in group 1 and group 2 underwent an initial visit, including the physical examination and provision of information by the dermatologist. Patients in group 2 also received an additional 20 min of individualized medication training. Efficacy, adherence and patient satisfaction were evaluated after 4 weeks of treatment., Results: We enrolled 104 consecutive patients with psoriasis: patients in group 2, who were trained, had a significant improvement at week 4 in BSA, PASI, dPGA and higher PPQ score, and were more adherent compared to those in group 1 who were not trained., Conclusion: Individualized medication training on the correct application of a topical therapy from a healthcare professional may improve patients' adherence, treatment tolerability and clinical outcomes.

Purpose: The purpose of this study was to provide quantitative evidence of patients' tolerance for therapeutic risks associated with psoriasis treatments that could offer psoriasis improvements beyond the PASI 75 benchmark., Materials and Methods: We used a discrete-choice experiment in which respondents chose between competing psoriasis treatments characterized by benefits (i.e. reduced plaque severity, reduced plaque area), risks (i.e. 10-year risk of tuberculosis, 10-year risk of death from infection), and treatment regimen. We analyzed choice data using random-parameters logit models for psoriasis affecting the body, face, or hands., Results: Of 927 eligible members of the National Psoriasis Foundation who completed the survey, 28% were unwilling to accept any greater risk of treatment-related infection mortality. Among the remaining 72%, respondents were willing to accept higher risks of infection-related mortality associated with treatment to completely remove plaques covering only 1% of the body, compared to reducing lesions from 10 to 1% of the affected area. This finding was more pronounced for lesions on the face., Conclusions: Most patients placed greater value on eliminating even very small plaques compared to avoiding treatment-related risks. The perceived importance of complete versus near-complete clearance was stronger than previously documented.

Background/objectives: Psoriasis is a chronic condition that may require long-term treatment for disease control. This analysis utilizes data from the Australasian Psoriasis Registry with particular attention to the impact of biologic therapy on DLQI, and the differences between the biologics in terms of DLQI score change., Methods: A retrospective review of patients enrolled in the Australasian Psoriasis Registry from April 2008 to August 2016 was conducted. All subjects from the registry that had DLQI and Psoriasis Assessment Severity Index (PASI) scores recorded at a baseline time point of treatment commencement, in addition to week 12 and 24 post commencement were included in the study. A window of ±3 weeks was permitted at these time points. Multivariate linear regression analysis was undertaken to identify significant predictors associated with change in DLQI., Results: Significant predictors of reduction in DLQI and PASI score from baseline to week 24 include use of adalimumab, infliximab, secukinumab and ustekinumab. Other therapies, including etanercept and oral systemic agents did not show significant change. Each class of biologic showed significant reductions in DLQI score, with IL-12/23 blockade showing the greatest reduction. Significant predictors of lack of reduction in DLQI score include a baseline PASI score <16, and history of diabetes, alcoholism or uveitis., Conclusions: Patients with moderate to severe chronic plaque psoriasis who are treated with biologics show the greatest reduction in DLQI score, compared with other treatments. Australian dermatologists are prescribing biologics when patients qualify for them in keeping with current guidelines.

Background: It is well known that psoriasis significantly impacts patients' quality of life (QoL). With the introduction of improved treatment modalities with biologic agents, more patients with moderate to severe psoriasis are able to achieve better results as measured by the Psoriasis Area and Severity Index (PASI). PASI 75 indicates a 75% or greater reduction in PASI scores from baseline and is indicative of excellent disease improvement. With newer biologic agents such as secukinumab, ixekizumab and brodalumab, patients are now capable of achieving PASI 90, introducing additional clinical decisions for physicians when considering treatment options. However, little is known regarding how the difference between achieving PASI-75 versus PASI-90 impacts patients' QoL., Objectives: The purpose of this study was to compare how achieving PASI 75 versus PASI 90 impacts QoL for patients with moderate to severe plaque psoriasis by using validated psychometric instruments that have been widely used in both dermatologic and non-dermatologic settings., Methods: Two separate open-label clinical trials were conducted to specifically assess QoL in patients with moderate to severe psoriasis on adalimumab or ustekinumab over 24 weeks. In addition to clinical assessments of psoriasis, patients completed two surveys: The Psychological General Well-Being (PGWB) Index and the Dermatology Life Quality Index (DLQI). Changes in total PGWB score and DLQI score at weeks 12 and 24 compared to baseline were compared between groups achieving PASI 75 and PASI 90., Results: There was no statistically significant difference in PGWB scores between patients achieving PASI 75 and patients achieving PASI 90 in the adalimumab treatment group (week 12 p = .21, but there was at week 24 p = .05). There was a statistically significant difference in DLQI between the patients achieving PASI 75 and the patients achieving PASI 90 in the adalimumab treatment group at week 24 (p = .01), but not week 12 (p = .11). There was no statistically significant difference in PGWB scores between patients achieving PASI 75 and patients achieving PASI 90 in the ustekinumab treatment group (week 12 p = .11, week 24 p = .35). There was no statistically significant difference in DLQI between the patients achieving PASI 75 and the patients achieving PASI 90 in the ustekinumab treatment group at week 24 (week 12 p = .49, week 24 p = .11)., Conclusions: There has been tremendous attention surrounding newer biologic agents that can achieve PASI 90 and even PASI 100. Although the results are impressive with regard to physical improvement of psoriasis, there may not be a clinically significant difference in QoL when comparing patients who achieve PASI-75 versus PASI 90.

Objective: The Self-Assessment of Psoriasis Symptoms - Clinical Trials (SAPS-CT) and SAPS - Real World (SAPS-RW) were simultaneously created to assess the experience of plaque psoriasis in two unique contexts., Methods: Qualitative and quantitative research was conducted in four phases namely concept elicitation, questionnaire construction, content evaluation and psychometric evaluation., Results: Following concept elicitation, 18 concepts were selected to inform questionnaire construction of the SAPS-CT and SAPS-RW. To accommodate each context of use, the SAPS-CT asks respondents to rate the target symptom 'at its worst' in the 24 h prior to assessment, while the SAPS-RW asks respondents to rate the target symptom "on average" in the 7 days prior to assessment. Cognitive debriefing confirmed that patients could comprehend and provide meaningful responses to both versions and, after minor modifications, resulted in 11-item questionnaires administered in an observational study (N = 200). Results from the observational study informed further item reduction (SAPS-RW to six items and SAPS-CT to nine items) and demonstrated that scores from each were reliable (Cronbach's α > 0.90, test-retest intraclass correlation coefficient >0.70), construct valid and able to differentiate among clinically distinct groups., Conclusion: The SAPS-CT and SAPS-RW are content-valid PRO questionnaires capable of producing psychometrically sound scores when administered chronic to plaque psoriasis patients.

Purpose: The perspective of patients with psoriasis about medical care treatment goals and strategies is receiving increasing attention. Here, we performed a country-based analysis of the Multinational Assessment of Psoriasis and Psoriatic Arthritis (MAPP) survey, in order to provide specific information on patients' perspective of treatment of psoriasis in Italy., Methods: This was a systematic household telephone survey recruiting subjects by random digit dialing. Household members ≥18 years were included if they had ever been diagnosed with psoriasis., Results: About 12,785 households were screened in Italy. 132 patients were ineligible for the analysis, including patients with psoriatic arthritis. 359 patients were surveyed. About half of the patients had very mild disease with less than 1 palm skin involvement, and 38% had 1-10 palm skin disease. It is noteworthy that 48% of patients with widespread disease were not taking any medication. Patients indicated the relief of symptoms, including itching (54.9%), as the main goal for their current therapy, whereas 14.2% reported no specific expectation from their medication. Overall, 70% of patients declared to be satisfied by their therapy, in terms of primary goal reached., Conclusions: Our findings suggest that most psoriasis patients have mild/moderate disease in Italy, and that a portion of patients with severe disease does not receive an adequate treatment.

Introduction: Patient-reported outcome measures are increasingly utilized in dermatology to assess the impact of skin disease on quality of life. Despite recognition of the influence of skin disease on intimate relationships, an instrument to assess intimacy has not been developed. The objective of this study was to create the dermatologic intimacy scale (DIS) and administer the prototype to a patient population., Methods: A group of healthcare providers at the University of California San Francisco created the DIS prototype. A total of 1676 psoriasis patients of an online community were invited to complete a cross-sectional survey including demographic information, DIS, body surface area (BSA) and anatomical involvement., Results: A total of 1109 patients completed the survey in its entirety. Patients with moderate-to-severe psoriasis (BSA ≥3%) had a higher DIS score overall and for each individual question than patients with mild disease (BSA < 3%; p < .001). Patients with genitalia, nails, face, neck and scalp involvement had higher scores compared to patients without involvement (p < .001)., Conclusions: Patients with more extensive disease and specific anatomical involvement experience a greater impact on intimacy. Interpretation is limited by patient response rate, as patients with or without intimacy issues may be more or less likely to respond. Further analysis is necessary for validation and interpretation.

Background: Evidence on fumaric acid esters (FAE) in the treatment of pediatric psoriasis is scarce., Objective: Describe the effectiveness, influence on the quality of life (QoL) and safety of FAE in children with recalcitrant psoriasis in daily clinical practice., Methods: A prospective case series., Results: Fourteen patients with recalcitrant plaque-type psoriasis were described (mean age 13.7, range 8-17 years). Mean treatment duration was 48.6 weeks (range 12-124). Maximum daily dose varied between 180 and 1200 mg with a mean of 564 mg per day. Mean Psoriasis Area and Severity Index (PASI) (±SEM) at baseline was 10.5 (1.0) compared to 8.6 (1.1), 6.2 (1.6) and 4.9 (1.5) at week 12, 24 and 36, respectively. An improvement in PASI was observed in nine patients (64.3%). Mean CDLQI (±SEM) at week 0, 12, 24 and 36 was 8.9 (1.4), 6.8 (1.2), 3.7 (1.4) and 3.1 (2.0), respectively. Most common adverse events (AEs) were gastrointestinal complaints (n = 13, 92.9%) and flushes (n = 10, 71.4%). Lymphocytopenia (n = 5, 45.5%) and eosinophilia (n = 4, 36.4%) were frequently observed laboratory abnormalities. AEs were usually mild and transient. One serious adverse event, unrelated to FAE, was reported., Conclusions: FAE showed improvement of disease severity and QoL in the majority of children. Side-effects occurred frequently, but were usually mild and transient. FAE may be an alternative systemic treatment option for pediatric psoriasis, provided that also the long-term safety data are closely monitored, in particular lymphocytopenia.

Objective: To evaluate patients' assessment of therapy, efficacy, quality of life and treatment adherence in patients with scalp psoriasis treated with non-alcoholic mometasone emulsion or calcipotriol/betamethasone gel., Methods: Prospective, open-label, multicentre, non-interventional study. Patients with non-severe scalp psoriasis were treated with mometasone emulsion or calcipotriol/betamethasone gel. Evaluations included patient's global assessment of treatment, physician's global assessment of disease severity, quality of life (Dermatology Life Quality Index), physician's subjective evaluation of therapy, treatment adherence and adverse events., Results: Ninety-five patients treated with mometasone emulsion and 88 treated with calcipotriol/betamethasone gel were included in the intention-to-treat analysis. Patients' global assessment of treatment favoured mometasone emulsion over calcipotriol/betamethasone gel (p = 0.008), with treatment rated as good/very good by 91% versus 82.5%. Patients were less likely to report irritation of fingers' skin with mometasone than with calcipotriol/betamethasone (p = 0.0015). Severity of scalp psoriasis and quality of life improved in both groups. Adherence to treatment was similar in both groups. Physicians' perception of efficacy, tolerability and compliance was better for mometasone emulsion., Conclusion: Non-alcoholic mometasone emulsion achieved greater acceptability to patients and physicians than calcipotriol/betamethasone gel for the treatment of scalp psoriasis. Both topical treatments were similarly effective in terms of disease severity and quality of life.

No validated instrument exists to measure desire for improvement in psoriasis patients. To address this void, we conducted a single-center longitudinal study of 268 moderate-to-severe psoriasis patients to psychometrically validate the Desired Improvement Tool (DIT). The DIT is a single-item instrument scored 0-5 by the patient. A 0 indicates the patient is satisfied with disease level and does not desire further treatment. A 5 indicates a large amount of improvement is desired. The DIT demonstrated high test-retest reliability (Spearman, r = 0.97). Predictive and construct validity were moderate-to-high: r = 0.70 for BSA, 0.67 for PASI, and 0.56 for PGA and r = 0.67 for Life Quality Assessment (LQA), respectively. A sensitivity analysis revealed the DIT responded to changes in BSA. As a psychometrically valid tool, the DIT may guide clinical management of psoriasis patients by capturing an important clinical construct in an expedient and quantifiable manner.

Background: Moderate to severe plaque psoriasis (with or without psoriatic arthritis) places significant burden on patients' lives., Objective: Explore and document patients' experiences of living with psoriasis, including symptoms, treatments, impact on daily lives and patient-reported functioning., Methods: In a US-based, non-interventional study, narrative interviews were conducted at baseline and again within 16 weeks. In interviews, patients with moderate to severe psoriasis indicated symptoms, ranked symptoms according to level of bother and indicated areas of their lives affected by psoriasis. Transcripts of interviews were coded for themes. Measurements of psoriasis severity including BSA, PGA and PASI were recorded., Results: Symptoms reported most frequently included flaking/scaling (non-scalp areas), itching/scratching and rash, while the most bothersome symptoms were itching/scratching, flaking/scaling (non-scalp areas) and skin pain. Frequently reported impact areas were social and emotional., Conclusion: Broad-reaching interviews with patients with psoriasis show that these patients suffer in many aspects of their lives and in ways not indicated by typical psoriasis severity measures. Patients with psoriatic arthritis reported symptoms and disease-related complications at higher rates than those without arthritis. Physicians' explorations of the effect of psoriasis on patients' life events could aid in managing these patients.

Background: Evidence on effectiveness and safety of methotrexate (MTX) in pediatric psoriasis is scarce., Objectives: To study the effectiveness and safety of MTX in pediatric plaque-type psoriasis and its influence on quality of life (Qol) in daily clinical practice., Methods: Subset analysis of prospectively collected data extracted from the Child-CAPTURE registry, a single center, longitudinal, long-term, observational daily practice cohort of pediatric psoriasis patients. A maximum dose between 0.14 and 0.63 mg/kg once weekly was prescribed in 25 children. Primary endpoints were percentages of patients with ≥ 75% improvement in the Psoriasis Area and Severity Index (PASI) at week 12 and 24., Results: PASI75 was achieved in 4.3% and 33.3% of patients at week 12 and 24, whereas 40% and 28.6% reached PASI 75 at week 36 and 48. Median PASI and body surface area decreased from 10.0 (range 3.8-42.4) and 11.0 (range 3.5-72.0) at baseline to 4.3 (range 0-19.8) and 2.6 (range 0.0-39.6) at week 24, respectively. Physician Global Assessment improved significantly from 3.0 to 1.2 at week 24. A significant decrease in Children's Dermatology Life Quality Index from 9.0 to 3.8 at week 24 was found. Most reported adverse events were severe nausea (n = 5), infections requiring antibiotics (n = 5) and tiredness (n = 4)., Conclusions: MTX shows a positive effect on PASI scores, improves Qol and has a reasonable safety profile.

Background: Treatment refusal, which is defined as a patient actively refusing to take treatment despite physician recommendations, has never been evaluated in psoriasis., Objective: To investigate refusal of topical treatments by patients living with psoriasis in France., Methods: Using responses to an internet study, participants who refused topical treatment (n = 50) were compared to those who applied topical treatment (n = 205). Participants undergoing phototherapy, biotherapy, and oral treatment were excluded. Spearman rank correlations completed by Fisher's exact tests and Student's t-tests were performed., Results: Comorbidities, localization of lesions, and symptoms associated with psoriasis were not significant predictors of treatment refusal. Compared to patients who accepted treatment, more patients who refused treatment believed that psoriasis is not manageable (80.0% versus 61.5%; p = 0.01), that psoriasis treatments never work (58.0% versus 27.5%; OR: 2.09 p < 0.0001), and that all creams have the same effects (54.0% versus 31.7%; OR: 1.7, p = 0.003). Among patients who reported seeking medical attention from physicians, more patients in the treatment refusal group reported some level of dissatisfaction with their relationship with their physician than in the treatment acceptance group., Limitations: The validity of the self-reported treatment refusal could not be evaluated., Conclusion: Treatment refusal is an important element to be taken into consideration in the management of psoriasis.

Background: Psoriasis often poses a significant challenge to treat. Ultraviolet light band (UVB) treatment is widely used and well recognized. However, the frequent visits to the dermatologist may indirectly present an impediment to many of the patients' careers and every day life due to the vast time burden with subsequent lost work earnings. We investigated the cost-effectiveness of the psoriasis UVB treatment from a patient's point of view using time as a surrogate measure., Method: Twenty-five patients participated (17 males and 8 females) in the study. We registered the number of UVB treatments per patient as well as the patients PASI (psoriasis area and severity index) score at each treatment session. The time spent in relation to each treatment session was reported in a questionnaire given to the patient. Time Spent per delta PASI (TSdP) was defined as number of minutes to reduce the PASI score by one., Results: Seventeen (68%) of the participants needed less than 300 min to lower the PASI with one score. The rest (n = 7 (32%)) used more than 300 min to lower the PASI score by one. Thus, the TSdP distribution displayed two peaks; ><300 min/dPASI. Log-transformed linear regression model showed that the expected TSdP would decrease with 42% for each time the start PASI was doubled, i.e. the higher the PASI level at the beginning of the treatment, the lower the TSdP., Conclusion: The level of reduction in psoriasis severity compared with the amount of lost work time/earnings may pose a much higher impact for patients and society than what is currently recognized.

Background: Visible psoriasis skin symptoms have a severe psychological impact on quality of life. To improve clinical approaches, methods of assessing these aspects are needed., Objectives: To investigate the influence of psoriasis on patients' body image based on the Body Image Model (BIM)., Methods: In-depth semi-structured interviews were conducted. Transcriptions of the interviews were subsequently analyzed using concepts from the BIM., Results: Eight patients with severe to moderate psoriasis (PASI ≥10) were interviewed. Five thematic issues linked to the negative impact of psoriasis on patient body image were identified: body coverage, sexual inhibitions, the influence of social support, reduced exercise activity and a negative self-image. Furthermore, information obtained through the Dermatology Life Quality Index (DLQI) questionnaires did not entirely reflect statements from patients made during interviews., Conclusion: An altered body image has a psychosocial impact on patients with visible psoriasis that may result in increased body coverage, sexual inhibitions and reduced exercise activity. This further affects self-image negatively and influences how people with psoriasis handle the risk of metabolic syndrome. Assessment of patient body image using components of the BIM increases the possibility of identifying important psychosocial aspects of psoriasis and the related risk of metabolic syndrome and is thus a valuable support for the DLQI questionnaires.

Objectives: The psoriasis symptom inventory (PSI) is a patient-reported outcome measure for assessing symptom severity in patients with moderate-to-severe psoriasis. The primary objective of this study was to evaluate the measurement properties of the PSI., Materials and Methods: Analyses of psychometric characteristics (reliability, convergent and known-groups validity,responsiveness, item performance, and dimensionality) were conducted using data from a Phase II trail to evaluate efficacy of brodalumab in subjects with moderate-to-severe psoriasis., Results: The PSI had excellent internal consistency (α = 0.93-0.98) and good test-retest reliability (ICCs = 0.77-0.87). Convergent and discriminant validity was indicated by moderate-to-strong correlations between the PSI and Dermatology Life Quality Index scores, and small correlations between PSI total scores and ShortfFrm-36 Health Survey mental health, role emotional, and role physical scales. Known groups validity was shown as mean PSI total scores varied by Psoriasis Area and Severity Index (PASI) and Static Physician's Global Assessment (sPGA) defined groups (p < 0.001). PSI total scores were responsive to changes in clinical status as assessed by PASI (p < 0.001) and sPGA (p < 0.001). Unidimensionality of the PSI was supported., Conclusions: The PSI is a short and valid unidimensional measure of psoriasis symptom severity that is well suited for use in clinical trials.

Background: To improve health outcomes during the treatment for pruritic skin diseases, it is important to understand which factors most influence patients' concerns about oral antihistamine drugs., Objectives: To survey the nature of patients' concerns about oral antihistamine drugs and to examine the factors associated with them., Methods: Patients with pruritic skin diseases expressed their concerns regarding the use of oral antihistamine drugs. The independent effects of the patients' background characteristics on their concerns were examined by multiple logistic regression analysis., Results: A total of 291 outpatients were completed the study. Overall, 32% of patients were worried about using oral antihistamine drugs. The most common concern was about their adverse drug events (except drowsiness) and the effects of long-term use. Overall, being concerned about antihistamine use was found to be significantly and independently associated with a younger age, severe itching, being a homemaker, and having previous personal experience of embarrassment due to drowsiness caused by taking over-the-counter drugs., Conclusions: Several factors are associated with altered self-reported concerns about antihistamines. Our results suggest the importance of understanding the nature of patients' fears about oral antihistamine use so that sound advice can be offered to them in a timely manner.

Introduction: To describe and illustrate in a case-study design the development and design of a multidisciplinary training program for outpatient children and adolescents with psoriasis and their parents., Methods: For the development of the program, a steering group was assembled, systematic semi-structured interviews were held and the literature was reviewed., Results: Aim of the training program was to strengthen patients and their parents in coping with and diminishing psoriasis-related problems in an outpatient setting. The program included treatment modules of medical information and skin care, itch and scratch problems, psychological issues in coping with the psoriasis, sleep hygiene and relapse prevention. Descriptive results in the case patient showed improvement of all outcome variables in the expected direction., Conclusion: This is the first multidisciplinary training program for outpatient children and adolescents with psoriasis and their parents. It aims at improving coping skills and self-management and could be a promising addition to regular treatment.

Background: The patient-reported Dermatology Life Quality Index (DLQI) measures the impact of dermatologic diseases on patients' lives., Objectives: To evaluate the content validity of the DLQI in patients with moderate to severe plaque psoriasis., Methods: In a two-part interview, participants were first asked open-ended questions about the impact of psoriasis-related complaints and symptoms on their lives and activities. The DLQI was then administered and cognitive debriefing interviews assessed participants' understanding of the instructions, items, and response scales, and relevance of the specific items to their experience with psoriasis., Results: Twenty-one patients were interviewed at two US sites. Mean age was 48.8 years, 67% were white, and 43% reported Hispanic/Latino ethnicity. The majority reported living with a partner or spouse (81%) and working full time or part time (57%). Patients' spontaneous responses to open-ended questions were consistent with DLQI concepts and generally did not provide additional concepts. Most participants reported that the instructions, item content, and response scales were clear and easy to understand and relevant., Conclusions: The content of the DLQI included all important and relevant concepts from the perspective of patients with moderate to severe plaque psoriasis. This study provides further support for the content validity of the DLQI in this population.

Plaque psoriasis is associated with significant psychosocial, quality-of-life, and economic burden. The objective of this study was to quantify the value to patients of reducing the severity and size of plaque psoriasis lesions. Subjects included individuals with a self-reported diagnosis of plaque psoriasis from a nationally representative US household panel. Subjects completed a web-based conjoint analysis survey and chose between hypothetical treatments in a series of questions. Each alternative was defined by lesion severity, percentage of body surface area (BSA) covered by lesions, type of treatment, injection discomfort or pain (if treatment included injections), risk of serious lung infection, and monthly out-of-pocket cost. 28,200 panelists were invited to participate. 18,330 responded, 503 qualified, and 419 completed the survey. Mean age was 54.5 years and 52% were female. 64% (35%) of patients reported psoriasis severity as mild or mild to moderate (moderate to very severe). Patients were willing to pay $486.73 out-of-pocket per month to eliminate severe lesions covering 25% BSA on the arms and legs and $444.80 out-of-pocket per month to eliminate moderate lesions covering 4% BSA on the face. Individuals with plaque psoriasis are willing to pay substantial amounts to reduce lesion severity and percentage of BSA covered by lesions.

Background: The role of the patient-physician relationship is a key issue in the management of lifelong, chronic conditions such as psoriasis, with each side bringing different perspectives., Objective: To explore areas of congruence and disconnection in the relationship between psoriasis patients and dermatologists, with a focus on communication issues., Methods: Three discussion group sessions were held in four centers across the United States with dermatologists, patients, and a follow-up of the dermatologists after watching the patient discussion., Results: Patients want more information on psoriasis, fast treatments, clear expectations from the onset of therapy, and recognition of the emotional burden. Dermatologists found that patients do not receive or internalize adequate information and need further explanation of treatment regimens to increase compliance and patient satisfaction., Limitations: This was a qualitative study assessing the range of responses and was not a quantitative study designed to test specific hypotheses. The study may not be informative about the experiences of people with psoriasis not actively seeing a physician., Conclusions: Encounters between physicians and psoriasis patients can be enhanced by providing information on what psoriasis is, choosing fast-acting treatments that patients are willing to use, and providing written materials about the disease and treatment plan.

This study assessed the need for a 'very severe (BSA > 20%)' category for psoriasis. Though impact on quality of life differs between severe (BSA 11-20%) and very severe groups, considerable overlap exists between them. BSA > 10% predicts severity sufficiently, deterring the need for a 'very severe' category. Severity was self-assessed and may not reflect true clinical severity.

In this article, we report two cases of pustular psoriasis flaring up after fluoxetine administration. A 21-year-old male patient with localized pustular psoriasis became erythrodermic following commencement of fluoxetine. Even though the lesions were unresponsive to cyclosporine A (Cyc A) treatment, dramatic resolution was observed with discontinuation of fluoxetine. A 44-year-old female patient with pustular psoriasis who was on Cyc A and acitretin therapy was given fluoxetine for her psychiatric symptoms. In the following 5 days, her lesions flared. Owing to previous experience, fluoxetine was stopped. Her lesions improved dramatically in the following 3 days. Exacerbation of psoriasis with antidepressant therapy has been rarely described. An extensive review of the literature revealed four such cases, all of which were seen after the use of selective serotonin reuptake inhibitors (SSRI). A serotoninergic influence in the etiopathogenesis of psoriasis may be possible together with a pharmacogenetic difference in the drug metabolism of these patients. Considering the two patients we presented and the patients previously reported in the literature, aggravation of pustular psoriasis by SSRI should be borne in mind.

Objective: To assess which measures are utilized to quantify lesions, disease severity, and quality of life in the current literature on psoriasis vulgaris., Methods: A MEDLINE search was performed with the keyword 'psoriasis' and the following limits 'All Adult: 19+ years', 'published in the last 5 years', 'English', 'Randomized Controlled Trial', and 'Humans'. The 'Methods' section of the individual articles were reviewed for inclusion criteria that described the study participants' state of psoriasis or disease generalization at baseline, methods used to classify or measure psoriasis during the study, the primary and secondary endpoints, and the quality of life measures utilized in each study., Results: A search resulted in a total of 180 articles, out of which 134 were utilized for the review. The criteria most commonly utilized were 'moderate to severe psoriasis', 'BSA >/=10%', 'mild to moderate psoriasis', and 'severe psoriasis'. PASI was the most commonly used measure to describe the extent of psoriasis. The most common QoL measure used was DLQI, being used in 54.8% of the articles that used some form of QoL measure/s., Discussion: Various measures are being utilized for the same purpose of generalizing disease/lesion severity and determining 'quality of life'.

Objective: A clinical trial was performed to evaluate the efficacy, speed of response, side effects and quality of life of patients treated with calcipotriol/betamethasone dipropionate (Dovobet) for 4 weeks followed by maintenance with calcipotriol for 8 weeks (group A) versus calcipotriol (Daivonex) alone for 12 weeks (group B) for the treatment of psoriasis., Materials and Methods: A total of 150 patients were enrolled and randomized to groups A and B. PASI and Skindex-29 were considered the outcome measures., Results: Ninety-six patients completed the trial. At weeks 2 and 4, both groups showed a significant clinical improvement compared to baseline; group A demonstrated a higher clinical response compared with group B (p< 0.001). Treatment with calcipotriol was associated with a gradual improvement in group B and maintenance of the results in group A. Similarly, the quality of life assessment showed a marked improvement in terms of Skindex-29 in both groups at weeks 2 and 4 compared to baseline. Both treatments were safe and well tolerated., Conclusions: Our results demonstrate a higher efficacy and more rapid onset of action with the two-compound ointment compared with calcipotriol cream alone in short-term treatment. However, sequential application of calcipotriol allows maintenance of the results.

Objective: The effect of adalimumab on patient-reported outcomes (PROs) was evaluated in patients with moderate to severe psoriasis during the initial 16-week, double-blind period of a 52-week, Phase III, multicenter trial., Methods: Patients were randomized to placebo or adalimumab 80 mg at Week 0 and 40 mg every other week from Week 1 to Week 15. PROs were evaluated throughout the study and included the Dermatology Life Quality Index (DLQI), the Short Form 36 Health Survey (SF-36), the Work Productivity and Activity Impairment Questionnaire-Specific Health Problem (WPAI-SHP), and several patient-rated symptom scales., Results: The adalimumab-treated group reported significantly greater improvements in DLQI total score (p<0.001), SF-36 Physical Component Summary score (p<0.001), and Mental Component Summary score (p<0.001) compared with the placebo-treated group over 16 weeks. Significant differences, favoring adalimumab, were also seen for the DLQI subscale scores (p < 0.001); SF-36 scale scores (p<0.001); WPAI-SHP work impairment (p<0.001), activity limitation (p<0.001), and overall work impairment scores (p<0.001); patient's global assessment of disease severity (p<0.001), psoriasis pain (p<0.001), and psoriasis-related pruritus (p = 0.002)., Conclusion: Adalimumab was efficacious in improving dermatology-specific and general health-related quality of life, work and activity limitations, and psoriasis-related symptoms in patients with moderate to severe psoriasis over a 16-week period.

Background: The health-related quality of life and economic impact of psoriasis has been documented. However, the negative impact of psoriasis on the workplace is poorly understood., Aim/methods: Through anonymous surveys from 30 subjects of each of three psoriasis severity groups we aim to quantify the workplace impact experienced by psoriasis patients and factors that may contribute to this impact. Data were collected using several previously validated measures including the Work Productivity Assessment Index (WPAI), SF-8, Hospital Anxiety and Depression (HADS) and past medical/psoriasis history., Results: Psoriasis patients experienced negative impact at work as measured by the WPAI; this impact is directly associated with disease severity. The other instruments confirmed the negative impact of psoriasis though the degree of impact did not always correlate with disease severity or work impact. Owing to the relatively small numbers, the significance of these findings is not certain., Conclusions: This preliminary study finds that psoriasis is associated with a reduction in work productivity and social functioning; this may explain the relatively high cost of this disease on both a macro- and microeconomic level. As there was a lack of significant trends in this study, formal inferences are limited and further investigation is warranted.

Patients with psoriasis suffer from the effects of a chronic illness. One of the most bothersome aspects of the disease is a sense of loss of 'control.' 'Perceived control' is an important and well-studied psychological concept. The literature on perceived control offers guidance to help improve the physician-patient relationship and outcomes in chronic diseases such as psoriasis. Practical suggestions include the use of materials and other resources offered by patient advocacy groups (such as those from the National Psoriasis Foundation) and the development of a physician-patient relationship that gives the patient a sense of control of their disease.

Individuals with moderate-to-severe psoriasis perceive that the disease exerts profound emotional, social and physical effects on their lives, and a significant percentage report that they do not consider their treatment sufficiently aggressive. A survey of individuals with a variety of chronic diseases reveals that those with psoriasis have the lowest estimation of their health-related quality of life, lower than that of patients with arthritis, congestive heart failure, chronic lung disease or depression. Although psoriasis can be treated effectively, many treatments are associated with long-term risks. Toxicity-sparing treatment strategies that include combination, rotational and sequential regimens can help to control moderate-to-severe psoriasis while reducing risk. Algorithms for the treatment of moderate-to-severe psoriasis detail possible options for specific types of psoriasis and for patients with specific needs. The purpose of the algorithms is to make optimum use of phototherapy, traditional cytotoxic and immunosuppressive agents, retinoids, and newer biologic agents.