Quality of life of psoriasis patients

The contribution of the quality of life (QOL) dimension in the overall morbidity caused by psoriasis is being recognized increasingly in mainstream dermatology. This is exemplified by a recent position paper, which proposes that a QOL standard is better than a body surface area measurement for delineating psoriasis severity.1 Furthermore psoriasis has been shown to impact the QOL of the patient to the same degree as other more life-threatening disorders such as diabetes, heart disease and cancer.2 There is a debate about what constitutes QOL, and the definition of QOL ranges from a consideration of the function-based biomedical aspects of the disease with a focus on the patients’ capacity to function in manner that is consistent with their age and social role, to a more individualistic approach which takes into consideration each patients unique ‘life plan’ into consideration. The literature on the QOL assessment in psoriasis has largely focused on the more function-based or health-related QOL approach. The health-related QOL approach considers the impact of psoriasis on the patients’ physical, social, psychological and vocational functioning. The QOL in psoriasis should be assessed within a developmental context. In general, patients in the 18–45 age group experience more frequent problems related to both appearance/socialization and occupation/finances.3 The adverse effect upon the QOL lessens in the over-45 age group, with a further decline in the over-65 age group.3 This most likely reflects the fact that in earlier adulthood, when the individual is first establishing social relationships, entering the workforce and starting their career, the social stigma associated with psoriasis has the greatest impact. Contrary to studies in the 1970s which reported that women were more affected by the cosmetic disfigurement caused by psoriasis, it is important to recognize that in more recent studies both men and women are equally affected by the impact of psoriasis on the appearance and socialization.3 This may in part be indicative of the fact that it is more socially acceptable for men to express concerns about their appearance and in part the fact that an attractive appearance has played an increasingly important role on socialization for men over the last 20 years.3 Another developmental consideration is the finding that younger patients with early onset psoriasis (onset age <40 years) are more likely to have greater genetic susceptibility and tend to experience more severe and recurrent disease.4 Patients with early onset psoriasis are also likely to have certain personality traits, such as greater difficulties with the expression and assertion of anger.5 Most of the psoriasis-related stress arises from the social stigma and resultant reactions of people in social situations, and difficulties with assertiveness may render these patients more vulnerable to the psoriasis-related stresses.5 The clinician should be especially sensitive to this possibly more vulnerable subgroup of patients with early onset psoriasis, who are less likely to readily express or volunteer their feelings. There is a relatively large body of literature on the role of stressful life events in the onset and/or exacerbation of psoriasis. It is important to recognize that the impact of psoriasis upon the QOL can also result in significant daily stress6,7 and greater psychological morbidity8 for the patient. Comparison of the psychocutaneous characteristics of patients who reported that stress exacerbated their psoriasis (i.e. the high stress reactors or HSR) to the subgroup that reported no significant association between stress and their psoriasis (i.e. the low stress reactors or LSR) revealed that the HSR had more cosmetically disfiguring psoriasis in ‘emotionally charged’ areas, i.e. their psoriasis was more severe in body regions such as the face, neck, scalp, forearms, hands and genital region,6 in contrast to the LSR. Among the HSR, psoriasis in these regions is more likely to be cosmetically disfiguring and affect socialization and sexual functioning. As expected, the HSR reported greater psoriasis-related stress than the LSR.6 The HSR also reported more frequent flare-ups of their psoriasis.6 It is possible that in some cases, the chronic low-grade stress or daily hassles resulting from having to cope with the impact of psoriasis upon the QOL can in turn exacerbate the psoriasis. These findings suggest that even clinically mild disease, when cosmetically disfiguring or affecting the genital regions, should be treated aggressively. This may be especially relevant for psoriasis, as in contrast to other stress-reactive dermatoses such as urticaria, acne, alopecia and eczema, psychosocial stressors predated the onset and/or exacerbation of psoriasis most frequently,9 suggesting that psoriasis tends to be the most sensitive to stress. It is important to recognize the presence of depressive disease in psoriasis, which may be primary or secondary to the psoriasis. In a survey of 217 patients, 9.7% of patients reported wishes to be dead and 5.5% reported active suicidal ideation at the time of the study.10 Suicidal ideation in psoriasis was associated with higher depression scores and higher patient self-ratings of psoriasis severity.10 Furthermore, the severity of depression has been shown to increase with increasing pruritus severity, and a decrease in pruritus pre- to post-treatment correlated with a decrease in the severity of depression.11 The depressed clinical state may decrease the threshold for pruritus, which is one of the most distressing symptoms of psoriasis.11 These findings highlight the multifaceted and possibly bidirectional relation between psoriasis severity, psychological factors and QOL, and emphasize the importance of considering the QOL dimension in the overall management of the psoriasis patient. In this issue (pp. 267–271), Devrimci-Ozguven, Kundakci, Kumbasar and Boyvat have examined the effect of stressful life events and psychopathology such as depression and anxiety, on the onset and exacerbation of psoriasis. The authors report that 68% of their 50 subjects reported a stressful life event in the previous 3 months, prior to the onset of their psoriasis, and furthermore there was a direct correlation between psoriasis severity and both ‘low affective expression’ and high depression scores. Their findings are consistent with previous studies and further highlight the importance of the psychosocial dimension in psoriasis.

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