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Background: Patients with psoriasis have increased risk of suicidal ideation and behavior (SIB) and depression. Bimekizumab, a biologic that inhibits interleukin (IL)-17A and IL-17F, received Food and Drug Administration approval in 2023 for moderate to severe plaque psoriasis, following 2021 European Medicines Agency approval., Objective: To report SIB and depression in patients with moderate to severe psoriasis treated in bimekizumab clinical trials., Methods: Mental health changes, including neuropsychiatric events, were actively monitored across 9 bimekizumab clinical trials in psoriasis phase 2/3 trials. The patient-reported electronic Columbia-Suicide Severity Rating Scale (measuring SIB) and Patient Health Questionnaire-9 (measuring depression) were administered, monitored by an independent Neuropsychiatric Adjudication Committee., Results: Throughout 7166 patient-years (PY) of bimekizumab exposure, the adjudicated SIB rate was 0.13/100PY; SIB ranges for the general psoriasis population and patients receiving anti-IL-17A/anti-IL-23 therapies are 0.09 to 0.54/100PY and 0.09 to 0.19/100PY, respectively. At week 16, 92.9% vs 81.1% of bimekizumab- vs placebo-treated patients had no/minimal depression. Newonset positive electronic Columbia-Suicide Severity Rating Scale responses and mean Patient Health Questionnaire-9 scores were low for bimekizumab-treated patients., Limitations: Patient exclusion for significant/severe prespecified SIB/depression history., Conclusion: The long-term adjudicated SIB rate with bimekizumab was low and within ranges reported in the general psoriasis patient population and psoriasis patients treated with anti-IL-17A/anti-IL-23 biologics. Screening/monitoring questionnaires reported low SIB and depression levels., Competing Interests: Conflicts of interest All details of authors' affiliation or involvement in an organization or entity with a financial or nonfinancial interest in the subject matter or materials discussed in this manuscript are disclosed. AB: Served as a speaker (received honoraria) for Eli Lilly and Company, Pfizer, and UCB Pharma, served as a scientific adviser (received honoraria) for AbbVie, Abcentra, Aclaris, Affibody, Aligos, Almirall, Alumis, Amgen, AnaptysBio, Apogee, Arcutis, Arena, Aslan, Athenex, Bluefin Biomedicine, Boehringer Ingelheim, Bristol Myers Squibb, Cara Therapeutics, CTI BioPharma, Dermavant, EcoR1, Eli Lilly and Company, Escient, Evelo, Evommune, Forte Biosciences, Galderma, HighlightII Pharma, Incyte, InnoventBio, Janssen, Landos, LEO Pharma, Lipidio, Microbion, Merck, Monte Rosa Therapeutics, Nektar, Novartis, Overtone Therapeutics, Paragon, Pfizer, Q32 Bio, Rani, Rapt, Regeneron, Sanofi-Genzyme, Spherix Global Insights, Sun Pharma, Takeda, TLL Pharmaceutical, TrialSpark, UCB Pharma, Union, Ventyx, Vibliome, and Xencor, and has acted as a clinical study investigator (institution has received clinical study funds) for AbbVie, Acelyrin, Allakos, Almirall, Alumis, Amgen, Arcutis, Athenex, Boehringer Ingelheim, Bristol Myers Squibb, Concert, Dermavant, DermBiont, Eli Lilly and Company, Evelo, Evommune, Galderma, Incyte, Janssen, LEO Pharma, Merck, Novartis, Pfizer, Regeneron, Sanofi, Sun Pharma, Takeda, UCB Pharma, and Ventyx. AA: Served as a research investigator and/or scientific adviser to AbbVie, Almirall, Arcutis, ASLAN, Boehringer Ingelheim, Bristol Myers Squibb, Dermavant, Dermira, Eli Lilly and Company, EPI, Incyte, Janssen, LEO Pharma, Nimbus, Novartis, Ortho Dermatologics, Pfizer, Regeneron, Sanofi, Sun Pharma, and UCB Pharma. JFM: Consultant and/or investigator for AbbVie, Amgen, AstraZeneca, Biogen, Bristol Myers Squibb, Boehringer Ingelheim, Dermavant, Eli Lilly and Company, Incyte, Janssen, LEO Pharma, MoonLake Immunotherapeutics, Novartis, Pfizer, Sanofi-Regeneron, Sun Pharma, and UCB Pharma. BS: Consultant (honoraria) for AbbVie, Acelyrin, Alamar, Almirall, Alumis, Amgen, Arcutis, Arena, Aristea, Asana, Boehringer Ingelheim, Bristol Myers Squibb, Capital One, Celltrion, CorEvitas, Dermavant, Eli Lilly and Company, Evelo Biosciences, Imagenebio, Janssen, Kangpu Pharmaceuticals, LEO Pharma, Maruho, Meiji Seika Pharma, Monte Carlo, Novartis, Pfizer, Protagonist, Rapt, Regeneron, Sanofi-Genzyme, SG Cowen, Sun Pharma, Takeda, UCB Pharma, Union Therapeutics, Ventyx Biosciences, and vTv Therapeutics, stock options from Connect Biopharma and Mindera Health, speaker for AbbVie, Arcutis, Dermavant, Eli Lilly and Company, Incyte, Janssen, Regeneron, and Sanofi-Genzyme, scientific co-director (consulting fee) for CorEvitas Psoriasis Registry, investigator for CorEvitas Psoriasis Registry, and editor-in-chief (honorarium) for Journal of Psoriasis and Psoriatic Arthritis. DdC, LP, OD, JLS: Employees and shareholders of UCB Pharma. ML: Employee of Mount Sinai and receives research funds from AbbVie, Amgen, Arcutis, Avotres, Boehringer Ingelheim, Cara Therapeutics, Dermavant, Eli Lilly and Company, Incyte, Inozyme, Janssen, Ortho Dermatologics, Pfizer, Sanofi-Regeneron, and UCB Pharma, consultant for Almirall, AltruBio, AnaptysBio, Apogee, Arcutis, AstraZeneca, Atomwise, Avotres Therapeutics, Brickell Biotech, Boehringer Ingelheim, Bristol Myers Squibb, Castle Biosciences, Celltrion, CorEvitas, Dermavant, EPI, Evommune, Facilitation of International Dermatology Education, Forte Biosciences, Foundation for Research and Education in Dermatology, Galderma, Genentech, Incyte, LEO Pharma, Meiji Seika Pharma, Mindera, Pfizer, Sanofi-Regeneron, Seanergy, Strata, Takeda, Trevi, and Verrica., (Copyright © 2024 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Psoriasis is a chronic, multisystem, inflammatory disease that affects approximately 1% of children, with onset most common during adolescence. This guideline addresses important clinical questions that arise in psoriasis management and provides evidence-based recommendations. Attention will be given to pediatric patients with psoriasis, recognizing the unique physiology, pharmacokinetics, and patient-parent-provider interactions of patients younger than 18 years old. The topics reviewed here mirror those discussed in the adult guideline sections, excluding those topics that are irrelevant to, or lack sufficient information for, pediatric patients., (Copyright © 2019 American Academy of Dermatology, Inc. All rights reserved.)

Background: Psoriasis and biologic therapies have been associated with psychiatric illnesses., Objective: To determine if persons with psoriasis or those exposed to biologics are more likely to develop a psychiatric illness., Methods: Retrospective electronic medical records cohort study., Results: Individuals with psoriasis were significantly more likely to have a history of several medical (eg, cardiovascular illnesses) and psychiatric (eg, depression, suicide) illnesses than those without psoriasis. Those with psoriasis who were prescribed a biologic therapy were significantly less likely than those with psoriasis not prescribed a biologic agent to receive a psychiatric illness diagnosis (hazard ratio for any psychiatric illness 0.52, 95% confidence interval 0.51-0.53, P < .0001). With respect to any psychiatric illness, this finding was confirmed when comparing biologic therapy versus methotrexate treatment (0.80, 95% confidence interval 0.76-0.84, P < .0001)., Limitations: These findings were likely attributable to treatment selection bias., Conclusion: Individuals with psoriasis have an increased risk of several medical and psychiatric illnesses. Individuals with psoriasis prescribed biologic agents are less likely than those not prescribed biologic agents to develop psychiatric illnesses. Most likely because of treatment selection, individuals with psoriasis prescribed biologic therapy are not currently at increased risk of a psychiatric outcome., (Copyright © 2019 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Psoriasis Area and Severity Index (PASI) response rates have been the benchmark for evaluating treatment efficacy in trials involving moderate-to-severe psoriasis., Objective: To understand how dermatologists assess biologics and which trade-off rules they apply when planning psoriasis treatment., Methods: Two online surveys of 130 and 129 US dermatologists (surveys 1 and 2, respectively) were conducted with use of direct and indirect elicitation via discrete choice experiment. Respondents were asked to choose hypothetical biologics on the basis of 6 attributes (a ≥75% reduction from baseline in PASI score or a ≥90% reduction from baseline in PASI score, infection risk, dosing frequency, and 3 patient-reported outcomes [PROs] [relief of depression, relief of itching, and impact on usual activities])., Results: Most dermatologists (74% in survey 1 and 76% in survey 2) reported using both PASI and PROs when selecting a biologic. PASI response rate was the most important attribute (35%-38% of overall decision weight), whereas combined PRO attributes had similar importance (36% of decision weight). Infection risk and dosing frequency influenced the decision to a lesser extent., Limitations: Potential bias in considering 3 PROs versus 1 PASI rate and 1 safety attribute., Conclusion: PASI is most important for dermatologists selecting biologics, but PROs are also considered, especially when PASI response rate is similar between treatments. PRO data should be collected in trials involving moderate-to-severe psoriasis., (Copyright © 2019 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Perceived stigma among patients with psoriasis contributes to poor quality of life., Objective: To determine the prevalence and predictors of stigmatizing attitudes toward persons with psoriasis among laypersons and medical trainees., Methods: Laypersons were recruited from Amazon.com's Mechanical Turk (MTurk) (n = 198). Additionally, 187 medical students were recruited via e-mail. Participants completed an online survey in which they viewed images of persons with visible psoriasis. Participants reported their desire to socially avoid the persons in the images, their emotional responses to the persons in the images, and their endorsement of psoriasis-related stereotypes and myths., Results: MTurk participants endorsed social avoidance items such as not wanting to shake hands with (39.4%) or have the persons in the images in their home (32.3%). Participants stereotyped persons with psoriasis as contagious (27.3%) and endorsed the myth that psoriasis is not a serious disease (26.8%). Linear regression analyses showed that having heard of or knowing someone with psoriasis predicted fewer stigmatizing attitudes (P < .05). The medical students reported less stigmatizing attitudes than the MTurk participants (P < .01)., Limitations: Self-report, single-institution study., Conclusion: Stigmatizing views of persons with psoriasis are prevalent among people in the United States. Educational campaigns for the public and medical trainees may reduce stigma toward persons with psoriasis., (Copyright © 2018 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Psoriasis is a chronic, inflammatory, multisystem disease that affects up to 3.2% of the US population. This guideline addresses important clinical questions that arise in psoriasis management and care, providing recommendations on the basis of available evidence., (Copyright © 2018 American Academy of Dermatology, Inc. All rights reserved.)

Background: Patients with psoriasis are at an increased risk for depression. However, the impact of treatment on this risk is unclear., Objective: Evaluate the incidence and impact of treatment on depression among patients with moderate-to-severe psoriasis., Methods: We defined a study population within the Psoriasis Longitudinal Assessment and Registry and measured the incidence of depressive symptoms (Hospital Anxiety and Depression Scale-Depression score ≥8) and adverse events (AEs) of depression within cohorts receiving biologics, conventional systemic therapies, or phototherapy. Patients were evaluated at approximately 6-month intervals. Multivariate modeling determined the impact of treatment on risk., Results: The incidence rates of depressive symptoms were 3.01 per 100 patient-years (PYs) (95% confidence interval [CI], 2.73-3.32), 5.85 per 100 PYs (95% CI, 4.29-7.97), and 5.70 per 100 PYs (95% CI, 4.58-7.10) for biologics, phototherapy, and conventional therapy, respectively. Compared with conventional therapy, biologics reduced the risk for depressive symptoms (hazard ratio, 0.76; 95% CI, 0.59-0.98), whereas phototherapy did not (hazard ratio, 1.05; 95% CI, 0.71-1.54). The incidence rates for AEs of depression were 0.21 per 100 PYs (95% CI, 0.15-0.31) for biologics, 0.55 per 100 PYs (95% CI, 0.21-1.47) for phototherapy, and 0.14 per 100 PYs (95% CI, 0.03-0.55) for conventional therapy; the fact that there were too few events (37 AEs) precluded modeling., Limitations: Incomplete capture of depression and confounders in the patients on registry., Conclusion: Compared with conventional therapy, biologics appear to be associated with a lower incidence of depressive symptoms among patients with psoriasis., (Copyright © 2017 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Individuals with psoriasis are at increased risk for psychiatric comorbidities, including suicidal ideation and behavior (SIB)., Objective: To distinguish between the underlying risk and potential for treatment-induced psychiatric adverse events in patients with psoriasis being treated with brodalumab, a fully human anti-interleukin 17 receptor A monoclonal antibody., Methods: Data were evaluated from a placebo-controlled, phase 2 clinical trial; the open-label, long-term extension of the phase 2 clinical trial; and three phase 3, randomized, double-blind, controlled clinical trials (AMAGINE-1, AMAGINE-2, and AMAGINE-3) and their open-label, long-term extensions of patients with moderate-to-severe psoriasis., Results: The analysis included 4464 patients with 9161.8 patient-years of brodalumab exposure. The follow-up time-adjusted incidence rates of SIB events were comparable between the brodalumab and ustekinumab groups throughout the 52-week controlled phases (0.20 vs 0.60 per 100 patient-years). In the brodalumab group, 4 completed suicides were reported, 1 of which was later adjudicated as indeterminate; all patients had underlying psychiatric disorders or stressors., Limitations: There was no comparator arm past week 52. Controlled study periods were not powered to detect differences in rare events such as suicide., Conclusions: Comparison with controls and the timing of events do not indicate a causal relationship between SIB and brodalumab treatment., (Copyright © 2017 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Psoriasis is associated with psychiatric comorbidities; however, the relationship between psoriasis and suicidality is not well understood., Objective: To perform a systematic review and meta-analysis that elucidates the relationship between psoriasis and suicidality., Methods: Applying the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we systematically searched the PubMed, EMBASE, PsycINFO, and Cochrane databases. We searched literature published between 1946 and 2017., Results: We identified 18 studies with a total of 1,767,583 participants, of whom 330,207 had psoriasis. On the basis of random effects modeling, the pooled odds ratio (OR) for suicidal ideation among patients with psoriasis was 2.05 (95% confidence interval [CI], 1.54-2.74). Patients with psoriasis were more likely to exhibit suicidal behaviors (combined attempted and completed suicides) with a pooled OR of 1.26 (95% CI, 1.13-1.40). Subgroup analysis showed that patients with psoriasis were more likely to attempt suicides (OR, 1.32; 95% CI, 1.14-1.54) and complete suicide (OR, 1.20; 95% CI, 1.04-1.39) than those without psoriasis. More severe psoriasis and younger age were associated with greater likelihood of suicidality., Limitations: There are few studies examining suicidality in conjunction with psoriasis severity., Conclusions: Patients with psoriasis have a significantly higher likelihood of suicidal ideation, suicide attempts, and completed suicides. Among patients with psoriasis, those who are younger and whose psoriasis is more severe are at particular risk for suicidality., (Copyright © 2017. Published by Elsevier Inc.)

Background: Psoriasis is a chronic condition with negative impact on patients' quality of life that most often requires lifelong effective and safe treatment., Objective: This analysis focused on the effect of secukinumab treatment on patient-reported health-related quality of life as assessed by the Dermatology Life Quality Index (DLQI) in patients with moderate to severe psoriasis., Methods: The proportion of subjects achieving DLQI score 0/1 response at week 24, time to DLQI score 0/1 response, and sustained DLQI score 0/1 response up to week 52 were compared between secukinumab and etanercept., Results: Of 1470 subjects, 1144 received secukinumab and 326 received etanercept. DLQI score 0/1 response rates were significantly higher for secukinumab than for etanercept at week 24. The median time to DLQI score 0/1 response was significantly shorter for secukinumab versus etanercept (12 vs 24 weeks; P < .01). The majority of secukinumab-treated subjects achieved DLQI score 0/1 response at week 24 and sustained it through week 52 along with a 90% to 100% reduction in the Psoriasis Area and Severity Index total score response., Limitations: Placebo comparisons are limited during the maintenance period because of rerandomization at week 12., Conclusion: Secukinumab treatment provided faster and greater sustained improvements in quality of life than etanercept over 52 weeks, consistent with greater clinical response., (Copyright © 2016 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Psoriasis vulgaris is characterized by disfiguring and stigmatizing skin lesions. The links among lesions distribution, severity, and stigmatization remain unclear., Objective: We sought to investigate if the involvement of visible and sensitive areas is linked to stigmatization., Methods: In all, 115 patients with psoriasis vulgaris were assessed for disease severity, skin lesions distribution, itch, and stigmatization using the Feelings of Stigmatization Questionnaire. Quality of life was assessed with the Dermatology Life Quality Index and the World Health Organization Quality of Life-BREF., Results: The localization of psoriatic lesions on the back of hands was related to higher stigmatization levels (P = .011, total score of the Feelings of Stigmatization Questionnaire), but not the involvement of nails, the palms, the face, or the genital area nor overall disease severity. All patients reported some level of stigmatization, regardless of the localization of lesions and type of psoriasis. Higher levels of stigmatization characterized patients who claimed not to be able to hide their lesions by clothing (P = .025), women (P = .001), and the unemployed (P = .004). Stigmatization was the strongest predictor of quality of life impairment., Limitations: Only hospitalized patients were included., Conclusions: Psoriatic lesions on the back of hands are debilitating and warrant effective treatment. Special attention should be paid to female patients, who are more sensitive to stigmatization., (Copyright © 2016 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Background: New psoriasis therapies have increased the ability to achieve skin clearance. However, insufficient evidence exists on the impact of total skin clearance from the patient perspective., Objective: We sought to determine if complete skin clearance is clinically meaningful compared with treatment responses without clearance., Methods: Pooled data from 3 phase-III trials were used to compare results for patients with complete skin clearance (Psoriasis Area and Severity Index [PASI] 100 or static Physician Global Assessment score 0) with patients without complete skin clearance (PASI 75 to <100 or static Physician Global Assessment score 1) based on Psoriasis Symptom Inventory and Dermatology Life Quality Index., Results: Percentages of patients with Psoriasis Symptom Inventory score 0 were 45% for those achieving PASI 100 and 8% for PASI 75 to <100 (P < .001). Respective percentages with Dermatology Life Quality Index score 0/1 were 80% and 55% (P < .001). PASI 100 resulted in incremental improvement over PASI 90 to <100 (incremental differences of 28% for Psoriasis Symptom Inventory score 0 and 18% for Dermatology Life Quality Index score 0). Similar results were observed for static Physician Global Assessment scores 0 versus 1., Conclusions: Complete skin clearance represents a clinically meaningful end point and outcome for patients, reflected in experiences of no psoriasis symptoms and no impairment on health-related quality of life., (Copyright © 2016 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Background: The impact of palmoplantar psoriasis on health-related quality of life (QoL) is largely unknown., Objective: We sought to compare clinical characteristics and patient-reported outcomes between patients with palmoplantar psoriasis and moderate to severe plaque psoriasis., Methods: We conducted a cross-sectional study of patients with plaque psoriasis (N=1153) and palmoplantar psoriasis (N=66) currently receiving systemic or light treatment for psoriasis., Results: Patients with palmoplantar psoriasis were more likely to report Dermatology Life Quality Index scores that correspond to at least a moderate impact on QoL (odds ratio [OR] 2.08; 95% confidence interval [CI] 1.20-3.61); problems with mobility (OR 1.98; 95% CI 1.10-3.58), self-care (OR 3.12; 95% CI 1.24-7.86), and usual activities (OR 2.47; 95% CI 1.44-4.22) on the European Quality of Life-5 Dimensions questionnaire; and heavy topical prescription use of at least twice daily in the preceding week (OR 2.81; 95% CI 1.63-4.85) than those with plaque psoriasis., Limitations: Our assessment tools may not account for all dimensions of health-related QoL affected by palmoplantar disease, and these results may not be generalizable to patients with milder forms of psoriasis., Conclusion: Patients with palmoplantar psoriasis experience greater health-related QoL impairment and are more likely to report heavy use of topical prescriptions than those with moderate to severe plaque psoriasis., (Copyright © 2014 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Background: There is little evidence to guide the establishment of treatment goals for moderate to severe psoriasis in the clinical setting., Objective: We sought to compare Dermatology Life Quality Index scores and prescription topical medication use between patients with clear versus almost clear skin., Methods: This was a multicenter cross-sectional study of 97 patients with clear skin and 441 patients with almost clear skin receiving current systemic therapy or phototherapy for a primary indication of plaque psoriasis evaluated at 1 of 10 US outpatient dermatology sites participating in the Dermatology Clinical Effectiveness Research Network., Results: In adjusted analyses, patients with clear versus almost clear skin were more likely to report no impact of psoriasis on quality of life (relative risk 1.60; 95% confidence interval 1.37-1.86). Patients with clear versus almost clear skin were also more likely to report no prescription topical medication use in the preceding week (relative risk 2.08; 95% confidence interval 1.73-2.49)., Limitations: Cross-sectional design prohibits longitudinal assessment of outcomes., Conclusions: Clinically important differences in quality of life and prescription topical medication use exist between patients with clear versus almost clear skin. Collectively, our results indicate that achievement of clear skin may be an important clinical distinction among patients with moderate to severe psoriasis., (Copyright © 2014 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Numerous studies have analyzed the influence of psoriasis on the quality of life and psychosocial health of patients. However, few studies have addressed the effect of this disease on individuals living with these patients (cohabitants)., Objective: To analyze the influence of psoriasis on the levels of anxiety, depression, and quality of life of the cohabitants of psoriatic patients., Methods: The study included patients, cohabitants, and controls, a total of 130 participants. Their quality of life was measured with the Dermatology Life Quality Index (DLQI) and Family Dermatology Life Quality Index (FDLQI), and their psychological state with the Hospital Anxiety and Depression Scale (HADS). Demographic data of participants and clinical characteristics of patients were also gathered., Results: The presence of psoriasis impaired the quality of life of 87.8% of the cohabitants. FDLQI scores of cohabitants were significantly associated with the DLQI scores of the patients (rs = 0.554; P < .001). Anxiety and depression levels did not differ between patients and cohabitants, but were significantly higher than in the controls (P < .001)., Limitations: Additional studies with larger numbers of patients and cohabitants are required to analyze differences between groups according to psoriasis severity., Conclusion: Psoriasis markedly worsens the global well-being of patients and their cohabitants, who experienced an impairment of their quality of life and higher levels of anxiety and depression., (Copyright © 2014 American Academy of Dermatology, Inc. Published by Mosby, Inc. All rights reserved.)

Background: Scoring systems are indispensable in evaluating the severity of disease and monitoring treatment response., Objective: We sought to evaluate the competence of various nail psoriasis severity scoring systems and to develop a new scoring system., Methods: The authors conducted a prospective, observational, single-point study of 36 patients given the diagnosis of fingernail psoriasis. Seven scoring systems were evaluated: Nail Psoriasis Severity Index (NAPSI), modified NAPSI, target NAPSI, Psoriasis Nail Severity Score, Nail Area Severity, Baran, and Cannavò et al. All tools were correlated with the Physician Global Assessment. Obtained information was integrated into the Nijmegen-Nail psoriasis Activity Index tooL (N-NAIL), and interrater and intrarater reliability was assessed., Results: Physician Global Assessment showed an acceptable correlation with the scoring system designed by Baran (r = 0.735, P < .01) and the Psoriasis Nail Severity Score (r = 0.734, P < .01). Target NAPSI showed low correlation (r = 0.203, P > .05). The correlation between Physician Global Assessment and the N-NAIL was 0.861 (P < .01). Excellent agreement was found for the intrarater and interrater reliability of the N-NAIL., Limitations: Sample size was limited., Conclusion: An adequate nail psoriasis scoring system is needed, as studies of treatments for nail psoriasis are on the horizon. Clinical severity of nail psoriasis was best reflected by the N-NAIL, followed by the Baran system and the Psoriasis Nail Severity Score., (Copyright © 2014 American Academy of Dermatology, Inc. Published by Mosby, Inc. All rights reserved.)

Over the past 2 decades, considerable progress has been made to further elucidate the complex pathogenesis of psoriasis, facilitating the development of a new armamentarium of more effective, targeted therapies. Despite these important advances, substantial deficits remain in our understanding of psoriasis and its treatment, necessitating further research in many areas. In the sixth section of the American Academy of Dermatology Psoriasis Guidelines of Care, gaps in research and care were identified. We discuss the most important gaps in research that currently exist and make suggestions for studies that should be performed to address these deficits. These encompass both basic science and clinical research studies, including large, prospective epidemiologic studies to determine the true prevalence and natural history of psoriasis; further molecular studies in patients with psoriatic and psoriatic arthritis to understand the function of psoriasis susceptibility genes and to identify novel therapeutic targets; studies to examine the role of environmental factors in the development of psoriasis; further investigation of the relationship between psoriasis and cardiometabolic disease; studies that examine the role of adjunctive therapies such as psychological interventions in appropriate patient groups; and finally, studies to identify biomarkers of disease severity and treatment response to optimize patient therapy., (Copyright © 2013 American Academy of Dermatology, Inc. Published by Mosby, Inc. All rights reserved.)

Background: Psoriasis significantly impacts patients' quality of life., Objectives: The purpose of this study was to prospectively assess the quality-of-life impact of treatment for moderate to severe plaque psoriasis by using a validated quality-of-life psychometric instrument that has been widely used in nondermatologic settings., Methods: In all, 32 patients with moderate to severe plaque psoriasis received 24 weeks of adalimumab treatment. Patients completed the Psychological General Well-Being (PGWB) Index, which evaluates 6 domains including anxiety and depression. The primary end point was the change in total PGWB score at weeks 12 and 24 of adalimumab treatment compared with baseline., Results: Statistically significant improvement in the total PGWB score was documented by week 4. By week 24, all 6 PGWB domains showed statistically significant improvement from the pretreatment baseline., Limitations: One limitation of this study is that the comparison between our psoriasis data and PGWB data from other major medical conditions was not conducted in a head-to-head manner. Another limitation is that we did not have a controlled (placebo) arm., Conclusion: Based on PGWB scores, patients with untreated psoriasis have as much impairment in psychological well-being as patients with other major medical diseases including breast cancer, coronary artery disease, congestive heart failure, and diabetes and that potent intervention improves psychological well-being to where it is comparable with that of patients with asymptomatic hypertension. A prompt intervention with an effective dermatologic treatment is not only critical, but capable of restoring the physical and psychological well-being of patients with psoriasis., (Copyright © 2013 American Academy of Dermatology, Inc. Published by Mosby, Inc. All rights reserved.)

Background: Symptoms of psoriasis can be embarrassing and distressing, and may increase risk of developing psychiatric disorders in young people., Objective: We sought to compare incidences of psychiatric disorders between pediatric patients with psoriasis and psoriasis-free control subjects., Methods: Patients (<18 years) with continuous health plan enrollment 6 months before and after first psoriasis diagnosis (index date) were selected (Thomson Reuters MarketScan database, 2000-2006 [Thomson Reuters, New York, NY]). Patients with psoriasis (N = 7404) were matched 1:5 on age and sex to psoriasis-free control subjects (N = 37,020). Patients were followed from index date to first diagnosis of a psychiatric disorder (ie, alcohol/drug abuse, depression, anxiety disorder, bipolar disorder, suicidal ideation, eating disorder), end of data availability, or disenrollment. Patients with psychiatric diagnoses or psychotropic medication use before the index date were excluded. Cox proportional hazard models controlling for age, sex, and comorbidities were used to estimate the effect of psoriasis on risks of developing psychiatric disorders., Results: Patients with psoriasis were significantly more at risk of developing psychiatric disorders versus control subjects (5.13% vs 4.07%; P = .0001; hazard ratio = 1.25; P = .0001), especially depression (3.01% vs 2.42%; P = .0036; hazard ratio = 1.25; P = .0053) and anxiety (1.81% vs 1.35%; P = .0048; hazard ratio = 1.32; P = .0045)., Limitations: Retrospective, observational studies of medical claims data are typically limited by overall quality and completeness of data and accuracy of coding for diagnoses and procedures., Conclusions: Pediatric patients with psoriasis had an increased risk of developing psychiatric disorders, including depression and anxiety, compared with psoriasis-free control subjects., (Copyright © 2011 American Academy of Dermatology, Inc. Published by Mosby, Inc. All rights reserved.)

Background: Psoriasis has a profound negative effect on quality of life that is often underappreciated by health care professionals and the public., Objective: We sought to assess the perception of the burden of psoriasis relative to other medical conditions in first-year medical students, and to determine if wearing a temporary tattoo simulating psoriasis during a teaching exercise would change their perceptions., Methods: Participants completed a questionnaire assessing their perception of the impact of psoriasis and other common medical conditions (visual analog scale). Participants then wore a temporary tattoo of a psoriatic lesion for 24 hours and completed the same questionnaire after this exercise., Results: Of 91 students approached, 61 completed the study. At baseline, psoriasis (mean = 23.6) and eczema (mean = 23.3) were perceived as having the lowest physical burden of diseases queried (P < .0001), whereas the mental impact of psoriasis was scored comparably with arthritis, heart disease, and diabetes (mean = 45.1-56.7), but lower than cancer (mean = 82.2) and depression (mean = 93.8). After the exercise, the perception of the impact of eczema (physical: mean = 37.3, P < .0001; mental: mean = 66.6, P = .0005) and psoriasis (physical: mean = 37.8, P = .0014; mental: mean = 68.6, P = .0293) was significantly increased., Limitations: The exercise did not simulate the chronic nature of psoriasis or the scaling and pruritic characteristics of psoriatic lesions. The survey instrument used to assess empathy has not been previously validated and statistical analysis was limited by small sample size and the absence of a control group., Conclusions: Temporary tattoos are a novel and effective method of teaching medical students about the psychological burden of psoriasis., (Copyright © 2011 American Academy of Dermatology, Inc. Published by Mosby, Inc. All rights reserved.)

Background: Psoriasis adversely affects health-related quality of life (HRQoL) in adults; however, little information exists about its impact on children and adolescents., Objective: The effect of etanercept therapy on HRQoL compared with placebo was evaluated in children and adolescents with moderate to severe plaque psoriasis., Methods: HRQoL data were collected from patients 4 to 17 years of age in a randomized, double-blind, placebo-controlled, North American, phase III study of etanercept. Instruments for assessing HRQoL included the Children's Dermatology Life Quality Index (CDLQI), Pediatric Quality of Life Inventory (PedsQL), Stein Impact on Family Scale, and Harter Self-Perception Profile for Children., Results: Baseline CDLQI and PedsQL scores revealed reduced HRQoL in patients with psoriasis relative to comparative populations. Patients treated with etanercept demonstrated significantly higher mean percentage improvement in total CDLQI scores from baseline to week 12 compared with those treated with placebo (52.3% etanercept vs 17.5% placebo [P = .0001]). At week 12, patients who achieved 75% improvement in their Psoriasis Area and Severity Index score had higher percentage improvements from baseline in total CDLQI scores than those who did not have 75% improvement in Psoriasis Area and Severity Index score., Limitations: The PedsQL, Stein scale, and Harter profile demonstrated limited improvement in patients' HRQoL, suggesting that these scales may not be sensitive to issues that are relevant to children with psoriasis and their families., Conclusion: Etanercept therapy had a clinically and statistically meaningful impact on disease-specific quality of life (CDLQI) and a clinically meaningful impact on general quality of life (PedsQL) in children and adolescents with moderate to severe plaque psoriasis., (Copyright © 2010 American Academy of Dermatology, Inc. Published by Mosby, Inc. All rights reserved.)

Background: Anxiety, depression, and impaired health-related quality of life (HRQoL) are common in patients with psoriasis., Objective: We sought to analyze the effect of ustekinumab on these conditions in patients with moderate-to-severe psoriasis., Methods: Patients with moderate-to-severe psoriasis (n = 1230) were randomized 1:1:1 to receive 45 mg of ustekinumab, 90 mg of ustekinumab, or placebo. The Hospital Anxiety and Depression Scale was used to measure anxiety and depression, and the Dermatology Life Quality Index to measure HRQoL., Results: At baseline, 40.3% and 26.7% of patients reported symptoms of anxiety and depression, respectively, and 54.6% reported Dermatology Life Quality Index scores greater than 10, indicating a very high impact of disease on HRQoL. Greater improvements at week 12 in mean Hospital Anxiety and Depression Scale-Anxiety (13.9%), Hospital Anxiety and Depression Scale-Depression (29.3%), and Dermatology Life Quality Index (76.2%) scores were reported in ustekinumab groups compared with placebo (P < .001 each)., Limitations: Results for these measures are reported only through 24 weeks., Conclusion: Patients receiving ustekinumab reported significant improvements in symptoms of anxiety, depression, and HRQoL., (Copyright 2009 American Academy of Dermatology, Inc. Published by Mosby, Inc. All rights reserved.)

Background: Psoriasis is associated with health-related quality-of-life impairment and depression., Objective: We sought to determine the effect of adalimumab on depression symptoms in patients with psoriasis., Methods: Patients with moderate to severe psoriasis in a randomized, placebo-controlled, double-blind clinical trial were assessed for depression symptoms at baseline and week 12 or early termination (ET) using the Zung Self-rating Depression Scale (ZDS). The effects of adalimumab (40 mg every other week) versus placebo on ZDS score at week 12/ET were assessed using analysis of covariance. Relationships between ZDS and the Psoriasis Area and Severity Index (PASI), the Dermatology Life Quality Index, and the Short Form 36 Health Survey were assessed using Pearson correlations. Changes in ZDS score were compared for patients with and without a 75% or greater reduction in baseline PASI score., Results: Compared with the placebo group (n = 52), the adalimumab group (n = 44) experienced an additional 6-point reduction in ZDS score (95% confidence interval: 2.5-9.5; P < .001) by week 12/ET. Depression improvement was correlated with improvement in PASI (r = 0.5; P < .0001) and Dermatology Life Quality Index (r = 0.5; P < .0001). Greater ZDS score improvement was observed at week 12/ET in responders with a 75% or greater reduction in baseline PASI score than in nonresponders (10.6 [SD = 9.4] vs 1.4 [SD = 9.6]; P < .001)., Limitations: This analysis cannot distinguish whether adalimumab has a direct or indirect effect on depression., Conclusions: Adalimumab treatment reduced psoriasis symptoms, reduced depression symptoms, and improved health-related quality of life in patients with moderate to severe psoriasis., (Copyright 2010 American Academy of Dermatology, Inc. Published by Mosby, Inc. All rights reserved.)

Background: Psoriasis is a chronic skin condition that has a major impact on health-related quality of life (QOL). We evaluated health-related QOL via willingness to pay and a ranking task for 8 domains of health relevant to psoriasis: intimacy, physical comfort, self-care, ability to work or volunteer, ability to concentrate, emotional health, social comfort, and ability to sleep., Objective: The goals of the study were to pilot test a new method to measure QOL impact in psoriasis and identify the areas of life most affected by psoriasis., Methods: Forty participants with a history of psoriasis were interviewed in a face-to-face format. First, participants were asked to rank the 8 domains of health we were investigating. Second, patients were asked how much money they would be willing to pay for a hypothetical cure for each domain of health. Responses in US dollars were interpreted as strength of preference rather than absolute monetary values., Results: About half of the patients in the sample (48%) were female, 60% had a college degree or further education, and 38% had an income level over $45,000/y. Physical comfort, social comfort, and emotional health were highly ranked by more than 75% of respondents. Ability to concentrate was least likely to be affected by psoriasis with just a quarter (25.7%) of respondents ranking this domain as important. The median amount patients were willing to pay for a hypothetical cure of psoriasis specific to a particular domain was highest for physical comfort ($2000, 25th quartile = $500, 75th quartile = $5500) and emotional health ($2000, 25th quartile = $250, 75th quartile = $5000), and lowest for ability to sleep ($625, 25th quartile = $50, 75th quartile = $5000)., Limitations: The sample size is modest for this pilot study. Willingness to pay as a method of eliciting stated preferences for qualitative aspects of health may be influenced by individual perception of money., Conclusions: This study successfully pilot tested a willingness-to-pay method and a ranking task to measure the relative severity of 8 domains of health-related QOL and found that physical comfort, social comfort, and emotional health were the domains of health most affected by psoriasis.

Background: Previous studies of infliximab in psoriasis have demonstrated rapid improvement with induction therapy and sustained response with regularly administered maintenance therapy., Objective: The efficacy and safety of continuous (every-8-week) and intermittent (as-needed) maintenance regimens were compared., Methods: Patients with moderate-to-severe psoriasis (n = 835) were randomized to induction therapy (weeks 0, 2, and 6) with infliximab 3 mg/kg or 5 mg/kg or placebo. Infliximab-treated patients were randomized again at week 14 to continuous or intermittent maintenance regimens at their induction dose., Results: At week 10, 75.5% and 70.3% of patients in the infliximab 5 mg/kg and 3 mg/kg groups, respectively, achieved PASI 75; 45.2% and 37.1% achieved PASI 90 (vs 1.9% [PASI 75] and 0.5% [PASI 90] for placebo; P < .001). Through week 50, PASI responses were better maintained with continuous compared with intermittent therapy within each dose, and with 5 mg/kg compared with 3 mg/kg continuous therapy., Limitations: Longer term (>1 year) maintenance therapy and further study of infliximab serum concentrations over this period, in both PASI 75 responders and non-responders, would be preferable., Conclusions: Through week 50, response was best maintained with continuous infliximab therapy. Infliximab was generally well-tolerated in most patients.

Background: Medication nonadherence is a significant problem in psoriasis. Although previous research has aimed to quantify the prevalence of nonadherence in topical medication users, patient motivations for intentional nonadherence are not fully understood., Objective: Our purpose was to determine the relative importance of factors contributing to nonadherence in topical corticosteroid users with psoriasis., Methods: A survey was distributed to psoriasis patients visiting an outpatient clinic., Results: Among the 53 persons surveyed, medication nonadherence was 40%. Frustration with medication efficacy, inconvenience, and fear of side effects were the most important reasons patients deviated from usage instructions. Subjects who did not receive instructions on topical treatment duration used corticosteroids longer (>8 weeks) than subjects who were instructed (P < .05)., Limitations: A relatively small sample size prevented trends in demographic predictors of adherence from reaching statistical significance. The patient self-report format has the potential to introduce recall bias., Conclusions: Factors contributing to intentional nonadherence, including dissatisfaction with efficacy, inconvenience, and fear of side effects, are the most important patient-identified barriers to appropriate use of topical steroids in psoriasis. Clear patient instructions on the intended steroid treatment duration may reduce adverse effects from overuse.

Psoriasis and psoriatic arthritis are inflammatory immune-mediated skin and joint conditions with major impacts on patients' health-related quality of life (HRQOL). Physical manifestations include unsightly, scaly, pruritic plaques and inflamed joints for patients with psoriatic arthritis. These symptoms can severely impair physical functioning and occupational capability and negatively affect psychosocial domains. Consequently, patients often experience feelings of embarrassment, helplessness, and depression. Recent therapies, including the biologics, have been shown to improve not only the physical signs and symptoms of these conditions, but also patients' HRQOL. To accurately assess these improvements, standardized and validated instruments are needed. However, there are currently a limited number of feasible and validated tools available in dermatology for measuring HRQOL and function. Valuable insights can be acquired from the rheumatology field, and refinement of existing outcome measures through a cooperative and consensus building process between dermatologists and rheumatologists will lead to standardization of assessment tools in the years ahead.

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

Background: Psoriasis is a common disease with substantial effects on quality of life. Few quality of life studies have been performed in psoriasis patients from the general US population., Objective: To describe the determinants of quality of life in psoriasis patients from the US population., Methods: Patients were randomly selected from the US population. Patients who identified themselves as having been diagnosed with psoriasis by a physician were invited to complete a more detailed survey about quality of life., Results: Two hundred sixty-six psoriasis patients from the US population completed the detailed survey. Body surface area showed the strongest association with decrements in quality of life (Spearman 0.50, P < .0001). Younger patients and female patients also had statistically significant reductions in quality of life. Increasing psoriasis severity was associated with seeking care from multiple physicians and having decrements in income., Conclusion: Patients with more extensive skin involvement have greater reductions in quality of life. Female patients and young patients are affected to a greater extent.

Background: Psoriasis is a chronic, unpredictable, and incurable disease that has a negative impact on patients' quality of life. Palm and sole psoriasis can add to this negative impact as it directly affects activities of daily living., Objective: We sought to estimate the prevalence of palmoplantar psoriasis in a patient population and to explore associations with patient outcomes., Methods: In all, 317 individuals with psoriasis completed a comprehensive assessment battery. Patients with palmoplantar psoriasis (n = 124, 39%) were compared with patients without palmoplantar involvement with respect to functional disability, psychiatric symptoms, physical and social discomfort, self-reported psoriasis severity, and health-related quality of life., Results: Patients with palmoplantar involvement reported significantly greater physical disability and physical discomfort than patients without palmoplantar involvement (both P <.01). There were no differences between the 2 groups with respect to psychosocial outcomes., Conclusion: Patients with palmoplantar psoriasis are affected to a greater degree by the physical aspects of the disease than patients without palmoplantar involvement.

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

Background: Psoriasis affects 7 million people in the United States, causing substantial cost, social stigma, and disability., Objective: The purpose of this study was to evaluate the health effects of skin disease by comparing psoriasis to other primary medical disorders using 3 different scales of health-related quality of life., Methods: A self-administered questionnaire consisting of 3 health-related quality of life measures was given sequentially to 35 eligible patients with psoriasis presenting to the Dermatology Branch of the National Cancer Institute (NCI) for an investigational therapeutic protocol., Results: All patients (100%) agreed to participate. The median Psoriasis Area and Severity Index (PASI) score was 13.0. Overall, 82.9% at least often felt the need to hide their psoriasis, and 74.3% claimed their self-confidence was at least often affected by their psoriasis. The median EQ-5D health state utility score was 13.0% less than healthy individuals (P <.001). On the SF-36, the mean general health score was 13.2% less (P =.005) and the median social functioning score 18.7% less (P =.005) than that of patients with no chronic conditions., Conclusion: Individuals with psoriasis are significantly affected in their health state utility, perception of general health, and social functioning when compared with individuals without chronic disease and those with certain primary medical conditions.

Background: The assessment of psoriasis severity is complex and involves both the physical and psychologic assessment of the individual patient., Objective: We compared the Salford Psoriasis Index and several other tools for assessing psoriasis severity for their abilities to assess both the physical and psychologic effects of psoriasis., Methods: A total of 101 patients (44 women, 57 men) were assessed by means of the Salford Psoriasis Index (SPI), Psoriasis Area and Severity Index (PASI), Self-Administered PASI (SAPASI), Psoriasis Disability Index (PDI), Hospital Anxiety and Depression Scale (HADS), and Illness Perception Questionnaire (IPQ)., Results: The "signs" score of SPI (which measures the clinical extent of psoriasis), PASI, and SAPASI correlated well with each other (r = 0.69-0.99; P <.01). They also correlated significantly, but not as strongly, with scores of psoriasis-induced disability, the PDI and SPI "psychosocial disability" score (r = 0.46-0.51; P <.01), but not with general measures of psychologic distress. There was no significant correlation between the historical treatment, "intervention," score in SPI and either the physical or the psychologic score in the SPI. The PDI and "psychosocial disability" score of SPI correlated well with each other (r = 0.69; P <.01) as well as with the depression and anxiety subscale scores of HADS (r = 0.33 and r = 0.37; P <.01, respectively), the total number of symptoms suffered by the patient (r = 0.38; P <.01), and the belief that stress or worry were associated with psoriasis (r = 0.33; P <.01)., Conclusion: Physical scores of psoriasis severity such as PASI, SAPASI, and the "signs" component of SPI give a partial indication of psychosocial disability caused by psoriasis. In many patients, however, the physical score does not reflect psychosocial disability. Patients should be assessed by a more holistic approach, which takes into account both physical and psychologic measurements, such as used in SPI, when assessing the severity of psoriasis.

Background: The reduction of disability caused by psoriasis is an important issue in dermatology. It is thus important to assess the patients' appraisal of their health-related quality of life., Objective: The aim of the present study was to assess health-related quality of life among patients with psoriasis and to compare these estimates with population norms., Methods: The samples comprised 283 patients and 2323 control subjects representative of the general Norwegian population. Health-related quality of life was assessed by means of the SF-36., Results: Both demographic and clinical variables, such as age, gender, educational level, hospital setting, comorbidity, and physical symptoms, affected the different SF-36 scales among the patients. After adjustments had been made for age, gender, and educational level, it was seen that psoriasis patients reported significantly lower scores than the normal controls on all scales. The greatest difference was found on the role emotional scale. The smallest difference was found on the health transition scale., Conclusion: These results show that psoriasis patients report poorer health-related quality of life than the general population. Therefore patient care of psoriasis must give attention to the impact of the disease on different life domains.