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Background: Improving health-related quality of life (HRQoL), disease severity, and treatment adherence through patient education is an increasingly important, yet relatively new area in dermatology. This randomized controlled trial aims to contribute to this growing area of research by exploring the effects of a 9-week educational program for patients with chronic skin diseases., Objective: The aim of the study was to evaluate the effect of a multidisciplinary educational program on HRQoL and disease severity in patients with psoriasis or atopic dermatitis (AD)., Methods: Sixty-four patients with diagnosed psoriasis or AD were recruited from University Hospital Zurich and randomized (1:1) to the intervention or control group. To assess HRQoL, the following self-reported questionnaires were used: Dermatology Life Quality Index (DLQI), Skindex-29, EuroQol-5D (EQ-5D), RAND 36-Item Short Form Survey (SF-36), and Beck Depression Inventory (BDI) to measure depression symptoms. Psoriasis Area and Severity Index (PASI) and the Eczema Area and Severity Index (EASI) were used to capture disease extent. These scores were assessed at four study visits, which were performed at baseline and 3, 6, and 9 months after the start of the program., Results: At month 6, an improvement of at least 25% in BDI was recorded in 15 (68.2%) of 22 patients in the intervention group and 6 (27.3%) of 22 patients in the control group (difference 40.9%, p = 0.016). 53.3% (16 of 30) of patients achieved an improvement in one subdomain of the SF-36 score (role limitations due to emotional problems) at 6-month follow-up, compared with 23.1% (6 of 26) of those not attending the educational program (difference 30.2%; p = 0.042). No significant differences in DLQI, Skindex-29, EQ-5D, PASI, and EASI between both groups at the three time points were found., Conclusion: An educational program may improve HRQoL and depression status of patients with psoriasis or AD., (© 2022 The Author(s). Published by S. Karger AG, Basel.)

Background: Psoriasis is a chronic inflammatory skin disease that has a profound effect on health-related quality of life (HRQoL). Patient education programmes may help patients to gain life-long control over their chronic disease., Objective: This multicentre randomised controlled study evaluated whether a standardised multidisciplinary education programme was beneficial to psoriasis patients., Methods: Adults with moderate-to-severe psoriasis were randomly assigned (1:1) to an intervention group to receive an educational programme or to a control group to receive usual care. Randomization was stratified by previous treatment history. The primary outcome was HRQoL, assessed by scoring the Skindex-29 domains emotion, symptom, and functioning. Psoriasis severity was assessed using the psoriasis area severity index (PASI). Levels of perceived stress, patient knowledge about psoriasis, and patient satisfaction were also assessed. Follow-up evaluations were performed at 3, 6, and 12 months., Results: A total 142 patients formed the intention-to-treat population: 70 in the control group and 72 in the intervention group. Skindex component scores and the PASI were significantly lower at 3, 6, and 12 months as compared to baseline in both groups, but no significant differences were found between the groups. Knowledge about psoriasis improved significantly during follow-up amongst patients from the intervention group compared to controls (68% of correct answers vs. 56%; p < 0.01). Patient satisfaction with psoriasis management and treatment was also better in the intervention group., Conclusions: The standardised education programme did not improve HRQoL and disease severity in psoriasis, but led to a significant improvement in patient knowledge about the disease and increased patient satisfaction., (© 2021 S. Karger AG, Basel.)

Background: Alexithymia is a psychological construct that describes one's difficulty in understanding and describing their own emotions as well as differentiating feelings from bodily signals of arousal. In the general population, alexithymia's prevalence is approximately 10%. Alexithymia may act as a triggering factor for many medical and psychiatric disorders. In patients with physical disease, alexithymia's prevalence reaches up to 63%. Additionally, alexithymia is associated with worse outcomes and heightened psychosocial comorbidities., Objective: This review continues where an earlier review (Willemsen, 2008) left off to (1) clarify alexithymia's prevalence in dermatology patients and (2) further investigate alexithymia's impact on disease burden, psychosocial comorbidities, and treatment., Methods: Systematic searches on alexithymia and dermatologic conditions were conducted using PubMed, Embase, PsycInfo, and Web of Science databases from March 8, 2021, to March 12, 2021. Data from eligible publications, which were full-text, clinical studies published after September 1, 2008, and available in English, were extracted by two medical students and summarized., Results: Despite a small number of publications (n = 37), data showed a markedly greater prevalence and severity of alexithymia in patients with alopecia, vitiligo, psoriasis, hidradenitis suppurativa, atopic dermatitis, chronic idiopathic urticaria, and primary focal hyperhidrosis compared to healthy controls. Further, data consistently demonstrate a complex interplay between alexithymia, disease burden, and psychosocial comorbidity., Conclusions: Identifying and addressing alexithymia in dermatology patients may improve treatment outcomes, associated comorbidities, and health-related quality of life., (© 2022 S. Karger AG, Basel.)

Background: Real-world studies evaluating patients with challenging-to-treat localizations of psoriasis (scalp, nail, and palmoplantar) are limited., Objective: To characterize patients with versus without psoriasis in challenging-to-treat areas seen in routine US clinical practice., Methods: This retrospective observational study included all adult patients with psoriasis enrolled in the Corrona Psoriasis Registry between April 2015 and May 2018 who initiated a biologic therapy at registry enrollment. Patients were stratified by the presence of scalp, nail, or palmoplantar psoriasis (nonmutually exclusive groups). Patient demographics, clinical char-acteristics, disease activity, and patient-reported outcome measures (pain, fatigue, itch, EuroQol visual analog scale [EQ VAS], Dermatology Life Quality Index [DLQI], and Work Productivity and Activity Impairment questionnaire [WPAI]) were assessed at registry enrollment and compared between patients with versus without each challenging-to-treat area using nonparametric Kruskal-Wallis tests for continuous variables and χ2 or Fisher exact tests for categorical variables. Generalized linear regression models were used to estimate differences in disease activity and patient-reported outcomes between patients with versus without each challenging-to-treat area., Results: Among 2,042 patients with psoriasis (mean age [±SD], 49.6 ± 14.7 years; 51.5% male), 38.4% had psoriatic arthritis (PsA), 38.1% had scalp psoriasis, 16.0% had nail psoriasis, 10.9% had palmoplantar psoriasis, and 26.2% had a combination of ≥2 challenging-to-treat areas and PsA; only 34.2% had body plaque psoriasis without PsA or challenging-to-treat areas. Patients in all challenging-to-treat groups reported higher (mean [95% CI]) itch (scalp, 58.01 [57.62-58.40] vs. 54.35 [53.99-54.72]; nail, 56.42 [56.02-56.81] vs. 55.59 [55.20-55.97]; palmoplantar, 60.22 [59.86-60.59] vs. 55.15 [54.79-55.54]) and lower EQ VAS (scalp, 68.12 [67.78-68.48] vs. 69.46 [69.12-69.81]; nail, 66.21 [65.89-66.55] vs. 69.48 [69.14-69.83]; palmoplantar, 66.21 [66.07-66.75] vs. 69.29 [68.94-69.94]) scores than those without the respective challenging-to-treat localization. Patients with nail or palmoplantar psoriasis reported higher pain, fatigue, and DLQI scores than those without. Higher proportions of patients with scalp or palmoplantar psoriasis reported work impairment compared with those without., Conclusion: Two-thirds of patients with psoriasis who initiated biologic therapy had PsA and/or ≥1 challenging-to-treat area. Patients with challenging-to-treat areas had worse patient-reported outcome scores than those without, indicating a significant burden of challenging-to-treat areas on patients' quality of life., (The Author(s). Published by S. Karger AG, Basel.)

Background: The reported prevalence of depression among individuals with psoriasis varies substantially, and the effect of gender on depression distribution has revealed conflicting results. In addition, using medication to identify cases is uncommon., Objective: To study the prevalence of pharmacologically treated depression among individuals with and without psoriasis in a Swedish population using ICD-10 codes and data from the Swedish Prescribed Drug Register., Methods: A retrospective case-control population-based study was performed including all living individuals (age ≥18 years) in Region Jönköping, southern Sweden (n = 273,536). ICD-10 codes for the diagnosis of psoriasis (L40.*) and depression (F32.* and F33.*), and data on pharmacological treatment from the Swedish Prescribed Drug Register, were extracted from electronic medical records between April 9, 2008 and January 1, 2016. The extraction date was January 1, 2016., Results: The risk of pharmacologically treated depression was increased in individuals with psoriasis (age- and sex-adjusted OR 1.55; CI 1.43-1.68); 21.1% of women with psoriasis received pharmacological treatment for depression during the study period compared to 14.2% in the control population. Prevalence figures for depression were significantly higher in women with psoriasis compared to men. The risk of suffering from depression was highest among male and female patients with psoriasis under the age of 31 years., Conclusions: Depression is common among patients with psoriasis. The results of the current study underline the need for dermatologists to adopt a holistic approach, looking beyond the skin, when handling patients with psoriasis in every-day clinical practice., (© 2020 The Author(s) Published by S. Karger AG, Basel.)

Background: Psoriasis is a systemic inflammatory disease capable of creating stigmatization in the form of social exclusion and decrement of psychological conditions., Aim: The aim of the study was to determine the level of stigmatization in patients with plaque psoriasis., Methods: The study included 166 patients with plaque psoriasis (55.6% women and 44.3% men) with Psoriasis Area and Severity Index scores ≤10. The age of the study patients ranged between 18 and 72 years (arithmetic mean = 37.4; median = 38; standard deviation [SD] = 11.0). The mean age at the diagnosis of psoriasis was 21.5 years (median = 20; SD = 9.1) and disease duration varied from 2 to 59 years (arithmetic mean = 15.8; median = 15; SD = 11.3). The study patients completed the Polish version of the 6-item Stigmatization Scale and the 33-item Feelings of Stigmatization Questionnaire and a survey developed by the authors of this study, containing questions about the participants' sociodemographic characteristics (sex, age, place of residence, marital status, education, employment status) and information about their disease (location of psoriatic lesions, time elapsed since the diagnosis of psoriasis)., Results: The mean score for the 6-item Stigmatization Scale for the whole study group was 7.6 out of 18 points (median = 7; SD = 3.8; minimum = 0; maximum = 17). The average score for the 33-item Stigma Feelings Questionnaire in our series was 84.5 out of 165 points (median = 88; SD = 20.9; minimum = 30; maximum = 136). A statistically significant sex-related difference was observed in the 6-item Stigmatization Scale scores, with higher stigmatization levels found in men than in women (p = 0.0082). Moreover, significantly higher levels of stigmatization were observed in countryside dwellers (p = 0.0311) and unmarried persons (p = 0.0321). Patients with a longer history of the disease (≥15 years) scored significantly higher on the 6-item Stigmatization Scale (p = 0.0217) than those in whom psoriasis lasted less long, and presented with higher, at the threshold of statistical significance, scores for the 33-item Feelings of Stigmatization Questionnaire., Conclusions: Stigmatization awareness should be promoted among physicians and psoriatic patients to improve psoriasis management., (The Author(s). Published by S. Karger AG, Basel.)

Background: Psoriasis and atopic dermatitis are chronic skin diseases that greatly affect the quality of life. Both diseases can be triggered or exacerbated by stress., Objective: We aimed to differentiate personality traits between patients with chronic skin conditions and people treated for stress in a pilot study., Methods: Patients participating voluntarily in educational programs in Belgium and Switzerland were recruited to complete personality trait questionnaires, including the Temperament and Character Inventory (TCI) and the Tridimensional Personality Questionnaire (TPQ). A comparison was made with patients treated for work-related stress., Results: A total of 48 and 91 patients suffering from skin diseases and work-related stress, respectively, were included in the study. Based on the questionnaires, we found that dermatology patients were less persistent and impulsive than those with work-related stress. Dermatology patients also exhibited more rigidness and less focus on performance. Finally, patients with work-related stress seem more likely to change in response to health-promoting programs than patients with chronic dermatoses., Conclusion: Patients with chronic skin diseases may perceive and cope with stress differently in comparison to patients with work-related stress due to inherent personality traits. Therefore, stress coping mechanisms may differ among different diseases. More research is needed into the design of educational interventions and the impact of personality traits in disease-specific groups., (© 2020 S. Karger AG, Basel.)

Background/aim: Hidradenitis suppurativa (HS) is a chronic skin disease with a heavy impact on patients' quality of life (QoL). The aim of this study was to evaluate in detail the QoL impact of HS comparing it with other skin conditions, and in particular with psoriasis., Methods: Patients with a diagnosis of HS were recruited. QoL was measured using the Skindex-17 questionnaire., Results: Data were available for 69 HS patients. HS had the worst QoL among several skin conditions. Compared to psoriasis the mean symptom score was 69.4 versus 53.7, and the mean psychosocial score was 56.1 versus 32.7. Overall, the scores of patients with HS were higher than those of psoriasis patients on 16 of the 17 items of the Skindex-17., Conclusions: When compared to many different skin conditions, and in particular to psoriasis, HS was the most impairing condition, even at low levels of clinical severity., (© 2019 S. Karger AG, Basel.)

Background: Psoriasis is associated with psychosocial distress. Little is known about the relationship between psoriasis and mental health (MH) emergencies., Objective: To examine the associations of psoriasis and MH hospitalizations in the USA., Methods: Data from the 2002-2012 National Inpatient Sample were analyzed, including an approximately 20% sample of all US hospitalizations (n = 87,053,155 children and adults)., Results: Hospitalization for MH disorders occurred more commonly in those with psoriasis compared to those without psoriasis (4.04 vs. 2.21%). In multivariable logistic regression models, psoriasis was associated with higher odds of admission for any MH disorder overall (adjusted odds ratio [95% confidence interval]: 2.32 [2.24-2.41]), as well as 9 of the 15 MH-specific disorders examined. Associated MH disorders included: anxiety, schizophrenia, personality disorder, depression, substance use disorders, history of MH disorder, alcohol-related disorders, adjustment disorders, and cognitive disorders. Children with versus those without psoriasis were also more likely to have a primary hospitalization for any MH disorder (2.82 [2.24-3.56]). Psoriasis inpatients were also more likely to have a primary hospitalization for any MH disorder compared to those with alopecia areata (1.99 [1.45-2.74]) or hidradenitis suppurativa (3.97 [3.49-4.52]). Psoriasis patients hospitalized with any MH disorder had higher mean [95% confidence interval] cost of inpatient care (USD 11,004 [10,846-11,241] vs. 9,547 [8,730-10,364]; p < 0.0001) compared to those without psoriasis, with USD 1,610,860 excess costs annually, with the majority of the costs coming from depression and mood disorders., Conclusions: Children and adults with psoriasis had increased hospitalization for multiple MH disorders, which were associated with a considerable financial burden., (© 2019 S. Karger AG, Basel.)

Background: Switching between biologics is commonly performed for the management of plaque psoriasis. However, no evidence about switching from secukinumab to ustekinumab has been reported., Methods: This retrospective observational multicenter study aimed to describe efficacy and safety of ustekinumab in secukinumab nonresponder patients., Results: A total of 21 patients unresponsive to secukinumab were treated with ustekinumab for a mean period of 53.3 weeks. Ustekinumab was effective in reducing disease severity, with significant improvements of both psoriasis area severity index (PASI) and dermatology quality of life index (DLQI) scores. PASI score improvements of 31.8, 44, 77.8, 80.3, 80.5, and 89.6%, at week 4, 12, 24, 36, 48, and above 60 weeks, respectively, were detected (p < 0.05), achieving PASI 50, 75, and > 90 responses in 93.8, 87.5, and 50% of patients at week 48. Four patients withdrew from ustekinumab treatment because of inefficacy, and failure of multiple biologic agents (> 2) seemed to affect ustekinumab drug survival. No serious adverse events (AEs) were reported while 38.1% of patients experienced mild AEs., Conclusion: Ustekinumab was safe and effective in treating patients unresponsive to secukinumab., (© 2019 S. Karger AG, Basel.)

Background/aims: This study aimed to investigate the predicting values of depression and anxiety symptoms for clinical response to etanercept treatment in psoriasis patients., Methods: A total of 85 psoriasis patients who received 6 months of etanercept treatment were consecutively enrolled in this prospective cohort study. The Psoriasis Area and Severity Index (PASI) score was evaluated at month 0 (M0), M1, M3, and M6, and the corresponding PASI 75/90 response at each visit was assessed. Also, anxiety and depression symptoms were assessed by the Hospital Anxiety and Depression Scale (HADS) at M0, M1, M3, and M6., Results: Depression symptoms were observed to correlate with female gender (p = 0.004), longer disease duration (p = 0.018), and higher PASI score (p < 0.001), and anxiety symptoms were seen to be associated with female gender (p = 0.017), larger psoriasis-affected body surface area (p = 0.049), and higher PASI score (p = 0.017) in psoriasis patients. After etanercept treatment, HADS-Depression (HADS-D) and HADS-Anxiety (HADS-A) scores were both decreased at M1, M3, and M6 (all p < 0.001) compared with M0. Most importantly, baseline depressed patients presented with a lower PASI 75 response rate at M3 (p = 0.014) and M6 (p = 0.005), and a reduced PASI 90 response rate at M6 (p = 0.045) compared with baseline non-depressed patients. Furthermore, multivariate logistic regression analyses revealed that depression symptoms at baseline were an independent predictive factor for the lower possibility of both PASI 75 response (p = 0.048) and PASI 90 response (p = 0.048) achievements at M6 in psoriasis patients. However, no correlation of baseline anxiety symptoms with PASI 75/90 responses was observed., Conclusion: Depression symptoms at baseline independently predict a worse clinical response to etanercept treatment in psoriasis patients., (© 2018 S. Karger AG, Basel.)

Background: Many cases of psoriasis begin in adolescence. The affected adolescents face the combined physical and psychosocial challenges of their disease-free peers with the added complexity of a visible disease., Objective: To review the impact of psoriasis on the health-related quality of life (HRQL) in adolescents as compared to their peers with other chronic diseases and to determine the best tools to measure HRQL in this population., Methods: A systematic literature review was completed using PubMed., Results: 256 publications were screened for inclusion, 37 were relevant to objectives and included in the systematic review. Most studies are pediatric psoriasis studies with an adolescent subgroup, very few are dedicated to solely addressing HRQL in adolescents with psoriasis. Adolescents with psoriasis face both the challenges similar to an adult psoriasis population in addition to the complexities inherent to healthy adolescents. Studies often use a general pediatric HRQL measure, PedsQL 4.0, or a dermatology-specific measure adapted from an adult questionnaire. Only one psoriasis-specific measurement tool exists, and it is specifically for scalp psoriasis., Conclusion: Both dermatologists and primary care physicians should treat the visible cutaneous lesions and disease comorbidities and address the psychosocial impact of psoriasis in their adolescent patients. Use of both a general and dermatology-specific HRQL questionnaire may allow physicians to better identify the impact of the disease and recognize improvement or impairment over time., (© 2016 S. Karger AG, Basel.)

Psoriasis is a common chronic inflammatory skin disease observed in about 1-3% of the general population. About 60-90% of patients with psoriasis suffer from itching. Interestingly, in the past itch was not considered as an important symptom of psoriasis. Despite the high frequency of itch in psoriasis, the pathogenesis of this symptom is still not fully elucidated. Although most studies indicate neurogenic inflammation and the role of neuropeptides, other mediators may be important as well. The majority of psoriatic patients consider itch as the most bothersome symptom of the disease as it significantly alters daily functioning and psychosocial well-being. Patients with itch showed greater impairment of their health-related quality of life compared to those without itch, and the intensity of itch correlated with the degree of quality-of-life reduction. However, treatment options for itch in psoriasis are limited. Therapy of itch in patients with psoriasis should be directed toward the resolution of skin lesions, as disease remission usually is linked with itch relief. Recent studies have clearly pointed to an important role of apremilast and biologic agents in itch intensity reduction in subjects suffering from psoriasis. Other treatment modalities include antihistamines, especially with a sedative effect, narrowband ultraviolet B, and antidepressants (doxepin, mirtazapine, paroxetine). Support by family members and/or health professionals may also be of importance in helping psoriatic subjects cope with itch., (© 2016 S. Karger AG, Basel.)

Background/aims: Psoriasis as a dermatological disorder has complex effects on mental health and the psychological status of the patient. Many authors proposed that assessing how psoriasis affects a patient's life is better than a body surface area measurement for delineating psoriasis severity. Alexithymia is a personality dimension characterized by difficulty identifying feelings, difficulty describing feelings, and externally oriented thinking observed in many clinical conditions, especially in psychosomatic disorders. This study aimed to determine the prevalence of alexithymia in patients with plaque psoriasis compared with healthy participants, while taking into consideration demographic and clinical variables., Methods: We enrolled 250 patients with chronic plaque psoriasis, naïve to any systemic treatment, and 215 healthy individuals. The 20-item Toronto Alexithymia Scale (TAS-20) was used to assess alexithymia. Data analysis was done., Results: The mean TAS score was 53.5 (±15.3) for the patient group and 45.1 (±10.8) for controls (p < 0.0001). Compared to controls, the psoriasis group showed significant alexithymic features (32.4 vs. 9.3%), and no significant differences of alexithymia between patients with severe and mild psoriasis were observed. A significant relationship was determined between alexithymia and female gender and sensitive area involvement, such as the face, hands, and genital area., Conclusion: This study suggests that the assessment of alexithymia should be a part of the comprehensive care of patients with moderate to severe psoriasis. For this purpose, the TAS-20 is a useful and simple tool to be used in daily clinical practice., (© 2017 S. Karger AG, Basel.)

Objective: We aimed to assess the psychometric properties of the Psoriasis Family Index (PFI), a disease-specific instrument, to measure the secondary impact of psoriasis on the quality of life (QoL) of family members and partners of psoriasis patients., Methods: PFI data were collected from 150 accompanying family members of psoriasis patients attending the dermatology department of a secondary referral hospital. Rasch analysis was used to examine various psychometric properties of the PFI, including dimensionality, response category functioning, fit statistics, scale reliability and validity, item targeting and differential item functioning (DIF)., Results: The 15-item PFI with 4 response options showed good overall fit to the Rasch model. The response category almost entirely followed the Linacre criteria, demonstrating its optimal functionality. All items except one had good fit to the Rasch model. The mean fit residual for the items was -0.085 ± 1.184 (range -1.54 to 2.7). Strict unidimensionality was achieved following removal of the misfitting item 5. The revised 14-item PFI maintained strong reliability (person separation index = 0.87). The scale showed minor mistargeting (mean difference between person and item location = 0.95 logits). None of the items displayed DIF across gender or relationship type., Conclusions: The PFI is the first disease-specific measure to quantify the QoL of family members of psoriasis patients. Following the application of Rasch analysis we now recommend the use of a 14-item version of the PFI: question No. 5 from the 15-item version has been deleted. This study demonstrates the promising psychometric performance of the PFI and confirms its potential as a useful outcome measure in future clinical research., (© 2015 S. Karger AG, Basel.)

Background: The impact of various dermatological conditions on quality of life (QoL) has been extensively studied, however the impact of nail psoriasis on QoL is an underexplored area., Objective: To investigate the impact of fingernail psoriasis on patients' QoL., Methods: A cross-sectional observational study using validated questionnaires concerning QoL (SF-36, modified onychomycosis questionnaire) was performed in 49 patients with fingernail psoriasis., Results: The mean SF-36 scores for fingernail psoriasis patients were comparable to the mean scores of the Dutch reference population. However, mean scores on the modified onychomycosis QoL questionnaire for all domains were reduced. Localisation, gender and duration of nail psoriasis influenced the impact of nail psoriasis on patients' QoL., Conclusion: Fingernail psoriasis can interfere with patients' social, mental and physical well-being. Assessing patients' QoL in daily practice offers the opportunity of a patient-centred approach to treatment.

Background: Psoriasis is frequently associated with cardiometabolic comorbidities and depression that are risk factors for cognitive impairment., Objective: To investigate cognitive performance in psoriatic patients., Method: Cognitive performances were assessed by neuropsychological tests in 41 patients with psoriasis and 37 controls. Diagnostic criteria for mild cognitive impairment (MCI) were (1) subjective complaint of a memory deficit, confirmed by a relative or caregiver, (2) pathological performance on neuropsychological tests investigating cognitive domains, (3) normal performance of daily living activities and (4) no dementia. Neuroimaging was studied by high-field magnetic resonance imaging and cortical thickness analysis., Results: MCI was found in 18 out of 41 (44%) patients with psoriasis compared to 4 out of 37 (11%) controls (p = 0.002). In particular, patients with psoriasis had lower scores in the delayed recall of the Rey Auditory Verbal Learning Test (p = 0.04), Backwards Digit Span Test (p = 0.002), Weigl's Sorting Test (p = 0.01) and Trail Making Test B (p = 0.008). In the 7 patients submitted to cortical thickness analysis, a reduction in brain thickness in parahippocampal, superior temporal and frontal gyri of the left hemisphere was observed., Conclusions: Patients with psoriasis may have a precocious impairment of long-term verbal memory, executive functions and attention., (© 2014 S. Karger AG, Basel.)

Background: Impaired dermatological health-related quality of life (HRQoL) has been observed in hospital-based studies, but little is known on a population-based level., Objective: To investigate self-reported dermatological HRQoL in the general population., Methods: Hidradenitis suppurativa, psoriasis, pimples, hand rash or atopic eczema were identified using questionnaires in a 15,177 person population sample. A nested case-control study of 180 cases and 259 controls was made using the Dermatology Life Quality Index (DLQI), Skindex-29 and EQ-5D., Results: Cases had higher scores in DLQI and Skindex-29 and a lower score in EQ-5D, suggesting lower HRQoL. Adjusting for age and sex, the differences in Skindex-29 and DLQI were significant (p < 0.001)., Conclusions: Persons with self-reported skin morbidity had lower HRQoL than the general population. The impairment is not as significant as in studies of hospital-based cases, but considering the high prevalence of skin diseases it may still represent a significant burden of disease on society in aggregate., (© 2014 S. Karger AG, Basel.)

Psoriasis is a disease state that may present significant cumulative life course impairment (CLCI). The impact of psoriasis on CLCI can be divided into social factors such as stigmatization, psychological factors such as depression, and physical factors such as pruritis, pain and arthritis. With a bimodal age range at first presentation, psoriasis tends to affect those in the second and fifth decades of life. In accordance with the CLCI model, the age of first presentation may substantially affect an individuals' life course, with younger patients more susceptible to CLCI. Social, psychological, and physical factors also provide protection from CLCI: personality, coping mechanisms, social support, and treatment or therapy may act as positive factors and mitigate these damaging effects. As the time course of most clinical trials encompasses a fraction of a patients' life, the true nature of this impact has not been easily captured. Longitudinal CLCI data in psoriasis is limited and continued life course data is needed., (Copyright © 2013 S. Karger AG, Basel.)

Patients who suffer from inflammatory skin disease are at risk of stigmatisation and physical and psychological co-morbidities. To an extent these issues can be offset by effective coping strategies. The cumulative balance of these interactions will often lead to impairment, especially in those whose coping mechanisms are maladaptive or do not exist. When this situation arises, the detrimental effect of these various morbidities is termed 'cumulative life course impairment' (CLCI). We present 2 typical cases, one of a patient suffering from severe psoriasis and another of a patient suffering severe atopic eczema, as examples of how patients with inflammatory skin disease may be affected by CLCI. Their experiences demonstrate that the presence of inflammatory skin disease changes key life choices with resultant effect on career and relationships, amongst others. Although longitudinal evidence to support this CLCI is lacking, these patient narratives add support to the concept of CLCI., (Copyright © 2013 S. Karger AG, Basel.)

Background: Psoriasis in the genital area is often neglected, although it bothers a substantial number of patients., Objective: To study both the role of the physician in the treatment of genital psoriasis and the symptom intensity of these lesions as experienced by the patients., Methods: A detailed self-administered questionnaire (containing items on the role of the physician and genital symptom intensity, range 0-10) was filled in by members of the Dutch Psoriasis Society., Results: Data of 277 patients with genital psoriasis were analyzed. A total of 45.8% did not discuss the presence of genital psoriasis with their physician, 25% believed that the physician paid sufficient attention to genital lesions, and 67.8% never applied treatment for genital lesions. Mean symptom intensity ranged from 2.4 to 5.1, all scores being significantly higher for women compared to men. Severe symptoms were present in up to 43.5% of patients. Of these patients, up to 38.1% did not discuss the symptoms with their physician., Conclusion: The consultation rate for genital lesions is low, while numerous patients report a significant burden of disease., (Copyright © 2012 S. Karger AG, Basel.)

Background: Although clinical studies have shown efficacy of biological agents in moderate to severe psoriasis, observational studies of real-world effectiveness are rare., Objective: To analyse the psoriasis area and severity index (PASI) and quality of life by the EQ-5D questionnaire and dermatology quality of life index (DLQI) in psoriasis patients who switched from conventional systemic treatment to biological agents in clinical practice. Furthermore, to analyse patient groups with the highest benefit of biological agents., Methods: Longitudinal, observational study based on the Swedish National Registry for Systemic Treatment of Psoriasis, PsoReg. Outcomes of biological-naïve patients who switched to a biological agent (n = 267) were analysed before switch and at the first follow-up., Results: Patients significantly improved in EQ-5D, DLQI and PASI (p < 0.001). Patients with DLQI ≥10 and/or PASI ≥10 had the greatest benefits from biological agents in terms of EQ-5D., Conclusions: Patients with moderate to severe psoriasis benefit from biological agents in clinical practice; the patients with the highest benefits were those with high pretreatment PASI and DLQI scores., (Copyright © 2013 S. Karger AG, Basel.)

Background: The literature on predictors of health-related quality of life in psoriasis is inconsistent., Objective: To assess potential predictors of quality of life in psoriasis., Methods: In a cross-sectional study involving 130 dermatological practices and outpatient clinics, data of 1,210 patients with psoriasis were collected. Quality of life was evaluated using the Dermatology Life Quality Index. Medical history, clinical and sociodemographic characteristics, therapy and health care features were used as independent variables in a backward multiple regression analysis., Results: Twelve predictors were included in the model explaining 38% of variance in quality of life. The strongest predictor was daily treatment time (beta = 0.30), followed by patient-defined treatment benefit (beta = -0.18), disease severity (beta = 0.19) and treatment satisfaction (beta = -0.16)., Conclusion: Treatment burden requires special attention when quality of life in psoriasis is to be improved. Since the larger part of variance is left unexplained, further factors predicting quality of life have yet to be detected., (Copyright 2010 S. Karger AG, Basel.)

Nail involvement is an extremely common feature of psoriasis and affects approximately 50% of patients. Despite this, it is an often overlooked feature of the disease, and treatment tends to be focused on clearing the cutaneous component of psoriasis. Clinical manifestations of nail psoriasis are pitting, discolouration, onycholysis and subungual hyperkeratosis as well as nail plate crumbling and splinter haemorrhages. Nail psoriasis is associated with discomfort in many patients and leads to significant functional impairment and psychological stress. The often distressing appearance of affected nails impacts the patient tremendously in both work and social activities. Importantly, 80% of patients with psoriatic arthritis have nail psoriasis. This review discusses the incidence of nail psoriasis and the burden on the patient and illustrates when dermatologists are strategically placed to detect the early signs of more severe disease by promptly diagnosing and managing the nail component of psoriasis., (Copyright (c) 2010 S. Karger AG, Basel.)

Background: Although the Skindex-29 is among the most commonly used health-related quality of life instruments in dermatology, the interpretation of obtained scores is not well documented., Objective: To create categories of the scores of the Skindex-29., Methods: The Skindex-29 scores of454 Italian patients with 6 distinct skin diseases from a specialized center were analyzed using mixture analyses. The validity of the obtained categorizations was tested., Results: Mixture analysis showed 4 distinct components (categories) for the emotion and functioning scale and 5 for the symptom scale. The total Skindex-29 score was categorized into 4 levels. As expected, patients with inflammatory diseases had higher levels of impairment, those with vitiligo and alopecia areata had low symptom levels and those with nevi were predominantly located in the lower categories for each of the scales., Conclusion: The proposed categories of the Skindex-29 may ease the interpretation of obtained continuous scores., (Copyright (c) 2008 S. Karger AG, Basel.)

Background: Psoriasis can have a major impact on the lives of patients, the members of their families and their partners., Objectives: To develop and validate a disease-specific instrument to measure the secondary impact of psoriasis on the health-related quality of life (HRQoL) of family members of psoriasis patients., Methods: The development of the new questionnaire involved a number of different stages: qualitative interviews with family members/partners, formulation of the first draft, refinement, initial validation, further refinement and finally revalidation of the questionnaire., Results: Items for the measure were generated from the content analysis of interview transcripts. The psychometric evaluation of the final draft of the Psoriasis Family Index (PFI-15) was carried out in a new cohort of participants. The PFI-15 demonstrated high internal consistency (Cronbach's alpha = 0.86) and high test-retest reliability (intraclass correlation coefficient = 0.93). The construct validity was assessed by testing a number of a priori hypotheses about its construct; a moderate to strong correlation was seen between families' PFI scores and patients' Dermatology Life Quality Index scores (r = 0.54, p < 0.01) and Psoriasis Disability Index scores (r = 0.59, p < 0.01), and between families' PFI scores and patients' Psoriasis Area and Severity Index scores (r = 0.43, p < 0.01)., Conclusions: The PFI is a simple and practical measure to assess the HRQoL of family members/partners of patients with psoriasis., (2009 S. Karger AG, Basel.)

Background: An effective patient-physician relationship is important in the management of psoriatic patients., Objective: Our purpose was to investigate the efficacy of an educational intervention for patients with psoriasis in improving disease knowledge and attitude towards physicians and systemic treatments., Methods: The intervention consisted of a single, 2-hour educational programme conducted either by a dermatologist or by a dermatologist and a psychologist. Information on psoriasis and its treatment was given. A questionnaire concerning knowledge about psoriasis was administered before and after the programme, and after 6 months., Results: 123 patients were enrolled. They reported a high degree of satisfaction with the intervention, improvement in knowledge about the disease and a better attitude towards therapy. After 6 months a better knowledge about the disease and a higher attitude to treatment were retained., Conclusions: A single educational intervention may be helpful in improving psoriasis knowledge and give psychological relief to patients., (Copyright 2009 S. Karger AG, Basel.)

Background: Health-related quality of life (HRQOL) outcomes are associated with clinical response to treatment in psoriasis. However, the association between HRQOL outcomes and more substantial degrees of Psoriasis Area and Severity Index (PASI) response and physician and patient global ratings remains ill defined., Objective: This study examined the relationship between achieving a 75% or > or =90% improvement in PASI and HRQOL outcome measures., Methods: Secondary analyses were completed using data for 1,469 patients with moderate to severe plaque psoriasis from two adalimumab clinical trials. HRQOL was measured via the Dermatology Life Quality Index (DLQI) and the Short Form 36 (SF 36) Health Survey. Clinical response was assessed by the PASI, physician's global assessment and patient's global assessment status scores. Clinical response was categorized into 6 groups based on PASI response: <25% (n = 332); 25 to <50% (n = 137); 50 to <75% (n = 170); 75 to <90% (n = 288); 90 to <100% (n = 255), and 100% (n = 192). Analysis of covariance models compared baseline measures and 16-week changes in HRQOL scores., Results: Statistically significant differences were observed between PASI response groups in DLQI total scores and in SF 36 summary and scale scores (p < 0.0001). The PASI 100 and PASI 90 to <100 groups demonstrated a >10-point decrease in DLQI total scores. Moreover, these changes were statistically significantly greater than those observed for the PASI 75 to <90 group (p < 0.001) and the other PASI response groups (p < 0.001). For the SF 36, the greatest changes were observed in the PASI 75 to <90, PASI 90 to <100 and PASI 100 groups, which all had improvements of >4 points in the Mental Component and Physical Component Summary (MCS and PCS) scores. Statistically significantly greater differences in DLQI total and SF 36 summary and scale scores were also observed between patient's global assessment categories (p < 0.0001) and between physician's global assessment categories (p < 0.0001)., Conclusion: Improvement in PASI response of >75% corresponded to improvements in HRQOL outcome measures for patients with moderate to severe psoriasis. PASI 90 or 100 responders had greater improvements in DLQI total score than PASI 75 responders.

Background: Sexual life can be severely affected in patients with psoriasis. However, this component is not often assessed by clinicians., Objective: To estimate the prevalence of sexual impairment and its degree of association with clinical and personal factors among psoriasis patients., Methods: Sexual life impairment was investigated in all eligible adults hospitalized with psoriasis in a dermatological hospital from February 2000 to February 2002, using answers to specific items from two dermatology-specific questionnaires, and from two psoriasis-specific questionnaires. Clinical severity and psychological problems were also evaluated. The same questionnaires were collected a month after hospital discharge, to estimate changes from baseline., Results: Of 936 patients,from 35.5% (Psoriasis Disability Index) to 71.3% (Impact of Psoriasis on Quality of Life Questionnaire) reported to have experienced sexual problems because of psoriasis. A more severe disease and the presence of psychological problems were also associated with sexual impairment. At 1-month follow-up, a reduction of >75% in clinical severity was associated with a twofold probability of substantial improvement of sexual life., Conclusions: Sexual impairment is very frequent in patients with psoriasis. Single questions on sexual life from quality of life questionnaires provide a simple tool that may be useful in clinical practice to assess sensitive issues, and thus to provide better patient-physician communication., (Copyright 2007 S. Karger AG, Basel.)

Background: A recent refinement study suggested that a Rasch reduced version of the Impact of Psoriasis Questionnaire (IPSO) of 11 items most adequately assessed the psychosocial impact of US psoriasis patients., Objective: To test whether the IPSO would also behave well in a different population that varies culturally, demographically, and in disease severity., Methods: The psychometric properties of the IPSO, using classical test and item response theory (Rasch analysis), were assessed in 805 Italian psoriasis patients., Results: Patients with more severe psoriasis reported significantly higher impact on their HRQOL (p < 0.001) and the IPSO correlated well with the Skindex-29 (r = 0.74) confirming its validity. The response distribution was adequate for all items, except item 9. The Cronbach's alphas were excellent and the high item-rest correlations confirmed its homogeneity. Principal component analysis demonstrated one dominant factor with an eigenvalue of 4.47 (items loading >0.40). Overall, the 11 IPSO items fitted the Rasch model (p = 0.07) and all items demonstrated a logical threshold order. Of the 11 items, 2 items showed significant individual misfit and only 1 item demonstrated significant differential item functioning for age but none for gender or global severity score., Conclusion: The 11-item IPSO is a valuable psoriasis-specific HRQOL instrument in different populations., (2007 S. Karger AG, Basel)

Background: It has been proposed that depression plays a role in how psoriasis affects quality of life. However, primary data are limited., Objective: To investigate the role depression plays in how patients experience psoriasis., Methods: Cross-sectional study conducted between January and May 2005. Recruitment of 265 adults with prevalent psoriasis through Internet advertisements. Standardized assessment of depressive symptoms, health-related quality of life (HRQL), illness-related stress, and clinical severity of psoriasis using validated scales., Results: Thirty-two percent of all participants screened positive for depression. We observed a graded relationship between depressive symptoms and HRQL impairment (p < 0.001). Only 16.5% of those with high depression scores were currently treated for depression. Both dissatisfaction with antipsoriatic treatment and illness-related stress were highly associated with depression. After adjustment for HRQL, patients with more severe psoriasis were less likely depressed, although this association failed to reach statistical significance (multiadjusted odds ratio 0.37; 95% CI 0.13-1.02; p = 0.06)., Conclusion: Patients with high subjective distress and low objective measures of psoriasis should be evaluated for depression., (2007 S. Karger AG, Basel)

Background/aims: The management of psoriasis, which has a major impact on quality of life (QoL), deserves a specific attention to elderly patients' problems and needs. Our aim was to describe the QoL of elderly patients with psoriasis., Methods: This is a cross-sectional study on 305 psoriatic inpatients, aged > or = 65 years. QoL, measured by the Skindex-29, was compared in groups of patients based on clinical and sociodemographic characteristics, and the possible determinants of psychological distress were investigated., Results: The mean age of the patients was 71 years (range: 65-93). Clinical severity tended to increase with age. Psychological distress was higher in patients > 70 years of age, while QoL showed an improvement for all the Skindex-29 scales in older age groups. Gender (women vs. men), and Skindex-29 emotions and functioning scales emerged as associated with psychological distress, after adjusting for age and clinical severity., Conclusion: These observations indicate that clinical severity of psoriasis increases among very elderly patients and is associated with different levels of skin-related QoL and psychological distress. It is important for dermatologists to be aware of the specific impact of psoriasis in the different subgroups of the elderly population, to meet the peculiar needs of each group., (2007 S. Karger AG, Basel)

Background: Financial constraints challenge evidence of the effectiveness of dermatological inpatient management., Objective: To evaluate the effectiveness of hospitalization in atopic dermatitis and psoriasis regarding initial and sustained benefits., Methods: Prospective study on adults with psoriasis vulgaris (n = 22) and atopic dermatitis (n = 14). At admission, discharge, and 3 months after discharge, validated outcomes of objective and subjective disease severity were assessed by trained investigators., Results: Hospitalization resulted in substantial benefit in quality of life and clinical disease severity. Looking at mean scores, the observed benefit appeared stable until 3-month follow-up. The analysis of individual patient data revealed significant changes in disease severity between discharge and 3-month follow-up with some patients relapsing, others further improving. Reasons for hospitalization and treatment performed were not related to sustained benefit., Conclusions: In psoriasis vulgaris and atopic dermatitis, hospitalization effectively improved quality of life and clinical disease severity. Further research should focus on prognostic factors for sustained improvement.

Background: Psoriasis is often associated with the risk of physical disability, social discomfort and psychological disorders., Objectives: The aim of this study was to investigate the prevalence of depressive symptomatology among Italian patients with psoriasis vulgaris, in order to better evaluate the disease severity in this patient population., Methods: Five thousand Italian patients with psoriasis were mailed the Center for Epidemiological Studies-Depression Scale (CES-D) questionnaire, a 20-item instrument developed to perform epidemiological studies of depressive symptomatology in the general population. Questionnaires with responses to 16 or more items were considered evaluable., Results: We received evaluable questionnaires from 2,391 patients, including 1,528 men (63.9%) and 863 women (36.1%). Depressive symptomatology was observed in 1,482/2,391 patients (62% overall; females, 63%; males, 61%). Men < 40 years of age were significantly more likely to report depressive symptoms than were men > or =40 years of age (67 vs. 58%, respectively; p = 0.002). Depressive symptomatology was more prevalent in psoriatic patients with only primary or secondary education than in psoriatic patients with higher education (51 vs. 32%, respectively; p < 0.02)., Conclusion: Our results are consistent with previous studies showing that psoriasis is associated with profound psychological morbidity, in particular with depression in a large number of patients. It is important to consider this association in the overall management of psoriasis., (Copyright (c) 2006 S. Karger AG, Basel.)

Background: Personality and emotional factors are thought to influence the onset of psoriasis, the occurrence of relapses, and the sensitivity of this condition to dermatological treatments., Objective: To explore the relationships between emotional disorders and emotional information processing in the one hand, and psoriasis severity and response to treatment on the other., Methods: We recruited 93 patients through an article in the local press. These patients attended three consultations. We evaluated psoriasis severity by Psoriasis Area and Severity Index (PASI) score and response to treatment by change in PASI score from baseline to the 3-month visit. We screened for comorbid mental disorders, using the Mini International Neuropsychiatric Interview. We used the Hospital Anxiety and Depression Scale to assess anxiety and depressive symptoms. Alexithymia (difficulty in identifying and expressing emotions) was evaluated with the 26-item version of the Toronto Alexithymia Scale (TAS-26) and the ability to integrate and differentiate emotions (emotional awareness) was assessed with the Lane and Schwartz Levels of Emotional Awareness Scale (LEAS)., Results: Forty patients presented at least one psychiatric diagnosis and 33 were considered alexithymic (TAS > or =73). No psychological score was associated with baseline PASI score, which was higher in men and positively correlated with disease duration. Patients who considered their disease to be stress-reactive tended to have lower LEAS scores (p = 0.052). At the 3-month visit, PASI scores had significantly improved in the subset of patients (n = 67) presenting severe psoriasis at inclusion (PASI >2); emotional awareness and anxiety scores had also improved in these patients (p < 0.001), but dermatological and psychological changes were not statistically related. Dermatological improvement at 3 months with respect to baseline PASI was predicted by longer disease duration (>20 years) and lower baseline LEAS score (p = 0.044 and p = 0.021, respectively)., Conclusion: This study demonstrates the value of assessing the ability of patients with psoriasis to process emotional information, as defined by emotional awareness. Patients with low LEAS scores appear to be more reactive to stress, but also to be more responsive to treatment, suggesting the activation of a particular stress physiology by negative affective states that are not experienced., (Copyright (c) 2006 S. Karger AG, Basel.)

Background: Health-related quality of life (HRQOL) has increasingly been recognized as an important aspect of a comprehensive clinical assessment in dermatology., Objective: The aim of the present study was to translate and validate one of the most frequently used and established skin disease-specific HRQOL questionnaires originally developed in English for the German language area: the Skindex-29., Methods: 295 in-patients with psoriasis and atopic dermatitis completed the German translation of the Skindex as well as a number of additional skin disease-specific questionnaires. Data from 2 subsamples were analysed separately to test for the robustness of results., Results: Results from principal component analyses supported the scale structure of the original Skindex. Internal consistency coefficients were high for all scales. Further analyses supported the convergent validity of the German adaptation of the Skindex-29 as well as its sensitivity to change., Conclusion: The study provides evidence for the validity and reliability of the Skindex-29., (Copyright 2004 S. Karger AG, Basel)

Background: Psoriasis profoundly affects patient quality of life (QOL). Amevive (alefacept), a novel and selective biologic agent, was clinically effective and significantly improved QOL in a phase 2 study., Methods: The present placebo-controlled, randomized phase 3 study examined the effects of a 12-week course of intramuscular alefacept on QOL in 507 patients with chronic plaque psoriasis using both dermatology-specific questionnaires [Dermatology Life Quality Index (DLQI); Dermatology Quality of Life Scales (DQOLS)] and the Short Form-36 Health Survey (SF-36), a generic, general health questionnaire., Results: All 3 QOL measures (DLQI, DQOLS, SF-36) demonstrated that alefacept 15 mg was significantly more effective than placebo in improving QOL in patients with chronic plaque psoriasis. In addition, the improvements in QOL for patients in the alefacept 15 mg group were of similar magnitude for all 3 QOL measures., Conclusion: The findings of this study are an important addition to the QOL literature for psoriasis treatments., (Copyright 2003 S. Karger AG, Basel)

Background: Clinical observations suggest that psychological stress can induce exacerbation of psoriasis. It is hypothesized that these stress effects on the course and outcome of psoriasis are caused by neuroendocrine modulation of immune functions. Therefore we investigated the cardiovascular, endocrine and immunological response to a laboratory stressor in psoriasis patients and healthy controls., Methods: Untreated (n = 7) and PUVA-treated (n = 4) psoriatics and healthy controls (n = 7) were exposed to a brief laboratory stressor (public speaking and mental arithmetic). Heart rate and blood pressure, catecholamine, cortisol, and DHEA plasma concentration, as well as distribution of T and NK lymphocytes were analyzed before, immediately after and 1 h after stress exposure., Results: Heart rate and blood pressure increased in all three groups during stress exposure with the most pronounced changes in PUVA-treated patients. Psoriasis patients displayed higher adrenaline values but diminished cortisol and DHEA plasma concentrations compared to controls. NK cell numbers (CD16+, CD56+), but not T lymphocyte subsets, increased immediately after stress exposure in untreated patients and controls. This effect was significantly diminished in PUVA-treated patients., Conclusions: The data of this pilot study indicate an enhanced stress-induced autonomic response and diminished pituitary-adrenal activity in psoriasis patients. PUVA treatment seems to interfere with the cardiovascular and NK cell response to acute psychological stress. Future studies will analyze the stress-induced neuroimmunological mechanisms in psoriatics in more detail.

Background: Stigmatization is a central experience of patients with psoriasis with a broad psychic and social impact., Objective: The purpose of this study is to identify the dimensions of stigma experience by a Questionnaire on Experience with Skin Complaints (QES; 'Fragebogen zum Erleben von Hautbeschwerden')., Methods: 187 in-patients with psoriasis were examined with the QES, an adopted and extended (German) version of the Feeling of Stigmatization Questionnaire by Ginsburg and Link. A factor analysis of the questionnaire was conducted and the construct validity was evaluated., Results: Five factors were found: 'self-esteem', 'retreat', 'rejection', 'composure' and 'concealment'. Self-esteem, retreat and rejection are mainly influenced by 'problematic regions' affected by psoriasis, rejection also by 'visible parts' and retreat also by 'invisible regions'. The influences of age, age at onset and sex on the stigma experience are small but significant., Conclusions: The QES proved to be an economical and reliable psychometric instrument to differentiate the stigma experience of psoriasis patients.

Background: Patients suffering from severe psoriasis report high levels of personal distress and disability as a result of their disease., Objective: The purpose of this study was to examine the relationship between disease severity, personal distress and disability., Methods: Twenty-two patients provided a self-rating of disease severity and completed the Psoriasis Disability Index (PDI) and the General Health Questionnaire (GHQ). A dermatologist provided a clinical assessment from the case notes., Results: Although the clinical assessment was not related to patient ratings, patient-rated severity scores, GHQ and PDI were correlated with each other. GHQ could only be predicted by disease severity when it was mediated by PDI scores., Conclusions: These results indicated that psoriasis affects psychological distress through its effects on the patients' everyday lives.

Association of stress with psoriatic skin symptoms was studied in 13 patients with psoriasis by dividing the patients into low- and high-stress groups based on their clinical examination and answers to three questionnaires (General Health Questionnaire, a somatization scale, and a life change questionnaire). This study focused on skin mast cells and sensory nerves which are the principal components in neurogenic inflammation. Mast cells were stained enzyme-histochemically for tryptase and chymase, and neuropeptides substance P (SP), vasoactive intestinal peptide (VIP), and calcitonin gene-related peptide (CGRP) were demonstrated immunohistochemically. Compared to the low-stress group (n = 7), the patients in the high-stress group (n = 6) had more severe skin and joint symptoms. Furthermore, mast cells positive for chymase activity were prominently reduced, but tryptase-positive mast cells only slightly decreased in the lesional skin of the high-stress group. A similar tendency was also observed in the nonlesional skin. In the papillary dermis of the lesional skin, both VIP- and CGRP-immunoreactive nerves could be observed in the high-stress group whereas in the low-stress group these nerve fibers were hardly visible in the corresponding area. No association of SP with stress was observed. This study suggests that psychic stress is associated with exacerbation of psoriasis, and stress may induce alterations in the psoriatic lesions by increasing the neuropeptide content with a concomitant decrease in the activity of neuropeptide-degrading enzymes, especially mast cell chymase.

As the skin is an organ that has a primary function in tactile receptivity and reacts directly upon emotional stimuli, dermatological practice involves a psychosomatic dimension. It is, however, the high visibility of dermatoses and their easy accessibility which make the skin a direct target for behavioural problems. Furthermore, self-destructive tendencies and hypochondriacal features often express themselves through dermatological symptoms: dermatitis artefacta and skin hypochondriasis are among the specific psychocutaneous disorders discussed here. In view of the clinical interface between dermatology and psychiatry, general guidelines are formulated and specific aspects of psychotherapy, behavioural treatment and psychotropic drug treatment are discussed.

The Questionnaire for Measuring Factors of Aggression (Fragebogen zur Erfassung von Aggressivitätsfaktoren, FAF) was completed by 113 depressive patients, 38 psoriatics, and 32 healthy controls. The controls had the lowest aggression scores, the neurotic depressives the highest. The monopolar endogeneous depressives had extremely high scores for autoaggressions and extremely low ones for outward aggressions, whereas the psoriatics show a contrary tendency: extremely high scores for outward aggressions and very low ones for autoaggressions.

48 psoriasis were compared with patients suffering from a variety of psychosomatic diseases, with regard to neuroticism, extraversion and self-defensive attitude. In addition, a Social Anxiety Scale was administered to the psoriasis patients to evaluate the patient's concern of his appearance in social situations. Finally, some psychometric data, which differentiated between the males and the females of the psoriasis group, are discussed.

On the basis of the findings of this study it could be concluded that the hereditary proneness alone is not sufficient to cause the breakout of psoriasis. Only when additional causes intervene, the disease breaks out. The importance of stress and emotional factors in causation and precipitation of the disease is discussed. The traumatic emotional experience and the aggravation of disease as result of improper approach of the society towards the patient's illness is reviewed. The impact of the disease on the treating doctor and the doctor-patient relationship is reported. Means of prevention of the breakout of the disease and the proper approach of the doctor in treating his patient is suggested and specified.

Three experimental groups of patients with urticaria, psoriasis and alopecia were compared for hostile personality characteristics, states of anxiety and depression, neurotic syndromes and stress with a control group of patients with other skin diseases. The patients from each experimental group were found to be less dominant, more intropunitive, more extrapunitive and more neurotic than the control group. The following neurotic syndromes differentiated the experimental groups: non-specific anxiety states in urticaria patients; neurotic depression in the patients with alopecia, and a variety of neurotic syndromes in the psoriasis patients. All experimental groups scored significantly higher than the controls in stress experienced during the year preceding the onset or the exacerbation of the illness.