Report
Assessment of quality of life in patients with psoriasis: a study from Serbia Danijela Milcic1, MD, MSc, Slavenka Jankovic2, MD, PhD, Sonja Vesic1, MD, PhD, Mirjana Milinkovic1, MD, PhD, and Janko Jankovic3, MD, PhD
1 Institute of Dermatovenereology, Clinical Center of Serbia and Faculty of Medicine Institutes of 2 Epidemiology and 3 Social Medicine, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
Abstract Background Psoriasis has a substantial impact on patients’ quality of life. Objectives The aims of this study were to assess the impact of the clinical severity of psoriasis on patients’ quality of life and to determine the effects of psoriasis-related stress on patients’ everyday life.
Correspondence Danijela Mil ci c, MD, MSC Clinical Center of Serbia Institute of Dermatovenereology Pasterova 2 11000 Belgrade Serbia E-mail: [email protected] Conflicts of interest: None. doi: 10.1111/ijd.12391
Methods The cross-sectional study was conducted at the Institute of Dermatovenereology, Clinical Center of Serbia, Belgrade. The study included 201 patients (124 men and 77 women), aged 18–70 with a diagnosis of psoriasis, hospitalized or treated as outpatients during 2009. For the assessment of patients’ quality of life, the psoriasis disability index (PDI) was used. The stress related to psoriasis was measured with the psoriasis life stress inventory (PLSI) and disease severity with the psoriasis area and severity index (PASI). Results We found moderate correlation between PLSI and all PDI subscales and overall score (correlation coefficients ranged from 0.334 to 0.521). The correlation between PASI and PDI subscales was weak, while we failed to find any significant correlation between PASI and the PLSI. The results of multiple regression analysis indicated that stress, more severe disease, and lower educational level are significant determining factors of a poorer quality of life in patients with psoriasis. Conclusion Our results support the importance of assessing the quality of life in psoriasis and effects of stress in patients’ adjustment to their condition and may have important implications for a psychological stress management approach in the clinical management of psoriasis.
Introduction Psoriasis is an immune-mediated inflammatory skin disease with complex pathogenesis. It is a chronic, genetically determined disease, characterized by different clinical manifestations and unpredictable course. Generally psoriasis is not a life-threatening disease but has a profound negative impact on a patient’s quality of life.1–3 Although psoriasis affects approximately 2% of the world’s population,4 very few studies examined quality of life in patients with psoriasis in southeastern European.5,6 World-wide, it is well known that patients with psoriasis have difficulties in their daily activities, and occupational and sexual functioning.7–9 In addition, patients with psoriasis, significantly more frequently than the general population, have various psychiatric disorders, such as depression, anxiety, social isolation, even suicidal ideation.3,10–12 Owing to the visibility of skin lesions, patients may feel humiliated and embarrassed, and the chronic and recurring nature of the disease makes them ª 2014 The International Society of Dermatology
feel helpless.13–15 High levels of stress may be associated with worsening of the disease and lack of appropriate therapeutic response.16 Negative impact of psoriasis on a patient’s quality of life has been demonstrated in a number of studies, and its correlation with the demographic and clinical disease characteristics varies.5,17,18 Researchers have indicated that 30–40% of patients with psoriasis suffer significant psychological distress related to their disease.19 The aims of this study were to assess the impact of psoriasis (especially its clinical severity) on patients’ quality of life, and to investigate the effects of perceptions of psoriasisrelated stress on areas of disability in everyday life. Methods Patients A cross-sectional study was carried out at the Institute of Dermatovenereology, Clinical Center of Serbia (Belgrade), during 2009. The study group consisted of 201 consecutive International Journal of Dermatology 2014
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2
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Quality of life in psoriasis
patients with psoriasis, of both sexes, aged 18–70 years, with duration of the disease of at least three months before the
The validated and cross-culturally adapted Serbian versions of the used questionnaires showed good internal reliability across
examination. All patients were in the exacerbation stage of
scales (Cronbach’ s alpha was 0.84 for PDI and 0.78 for PLSI).
psoriasis. The majority of them (71%) required hospital admission while ambulatory patients accounted for a smaller part of the study group (29%). None of the patients has been treated with systemic therapy before examination. The study protocol was approved by the Ethics Committee of the Clinical Center of Serbia, Belgrade, and written informed consent was obtained from all participants.
Instruments A short standardized form was used to collect data regarding age, sex, education, duration of psoriasis, age at onset, and family history of psoriasis. Diagnosis of psoriasis was confirmed by experienced dermatologists. The psoriasis area and severity index (PASI) was used for the assessment of the disease severity.20 The PASI score is obtained as a result of evaluation of erythema, infiltration, desquamation, and area of the skin involved by psoriasis. It can vary from 0 (the lowest score) to 72 (the highest score) with higher scores indicating greater severity. In our study, mild psoriasis was classified as a PASI 25. To date, no consensus has been reached on the cut-off levels for the PASI. The reason that we used the above-mentioned cut-off values is that our study was carried out in the large tertiary care hospital (Institute of Dermatology, Clinical Center of Serbia) where serious skin conditions and illnesses are often cared for. If we used lower cut-off values as in most studies, the majority of our patients would be in one group – the group of patients with severe psoriasis – without a possibility for comparison. To evaluate the impact of psoriasis on the patients’ quality of life, we used the psoriasis disability index (PDI), a 15-item scale related to daily activities, work or school, personal relationships, leisure, and treatment effects.21 All the questions referred to events that had taken place in the preceding four weeks. The answers were scored from 0 to 3 (0, “not at all”; 1, “a little”; 2, “a lot”; 3,“very much”), producing a range of total PDI score from 0 to 45. The higher the score, the more quality of life is impaired. The 15-item version of the psoriasis life stress inventory (PLSI) was used to measure stress associated with having to cope with everyday events in living with psoriasis.22 For each item, patients were asked to rate the level of stress experienced over the previous four weeks on a four-point scale, from “not at all” to “a great deal”. According to the results of the total PLSI score (ranged from 0 to 45), patients were classified into two groups: high stress reactors (patients who reacted significantly to the stress associated with having psoriasis [score of ≥10]), and low stress reactors (patients who were not significantly affected by psoriasis-related stress [score of 25, n (%)
124 (61.7) 77 (38.3) 55 (27.4) 112 (55.7) 15 (7.5) 19 (9.5) 50.79 13.26 3.99 2.03 46.96 13.20 61 (30.3) 140 (69.7) 94 (46.8) 71 (35.3) 26 (12.9) 10 (5.0) 20.2 14.1 63 (31.3) 83 (41.3) 55 (27.4)
Table 2 Scores for demographic, clinical and quality of life variables in patients with psoriasis as a function of their family history of psoriasis (mean SD) Family history of psoriasis Variable
No (n = 140)
Age Duration of psoriasis Age at onset PASI PDI PLSI
52.41 3.73 48.69 19.13 19.04 14.84
12.69 2.11 12.78 13.29 9.59 11.05
Yes (n = 61) 47.57 4.57 43.00 22.70 19.82 18.46
13.62 1.69 13.39 15.75 10.06 10.54
P valuea 0.016 0.000 0.005 0.030 NS 0.032
NS, not significant; PASI, psoriasis area and severity index; PDI, psoriasis disability index; PLSI, psoriasis life stress inventory. a t-test.
not found for personal relationships and treatment related effects. The relationship between quality of life measures (PDI, PLSI) and PASI, expressed by Pearson correlation coefficients, is shown on Table 4. We found moderate correlation between PLSI and all PDI subscales and overall score (correlation coefficients ranged from 0.334 to 0.521). The correlation between clinical severity of psoriasis (PASI) and PDI subscales was weak, although statistically significant (correlation ª 2014 The International Society of Dermatology
Report
coefficients were between 0.163 and 0.321), while we failed to find any significant correlation between PASI and the PLSI. Patients whose distribution on the PLSI classified them as highly reactive to stress associated with psoriasis (score ≥10) in comparison with low stress reactive patients (score 25 n = 55
PASI (12–25) n = 83
3.45 2.20 1.71 3.12 0.93 11.17
8.48 3.96 2.06 4.73 1.20 20.43
3.32 2.43 1.64 3.47 1.00 9.57
8.74 4.64 2.14 5.37 1.40 22.29
P valuea
3.37 2.47 1.89 2.70 1.12 8.83
0.000 0.000 0.108 0.005 0.145 0.000
QoL, quality of life; PASI, psoriasis area and severity index; PDI, psoriasis disability index. a ANOVA. Table 4 Pearson correlation coefficients for relations between PDI, PLSI, and PASI
Employment Personal relationships Leisure Treatment PLSI PASI
Daily activities
Employment
Personal relationships
Leisure activities
Treatment effects
PDI (total score)
PLSI
0.703** 0.467** 0.543** 0.430** 0.462** 0.206**
0.532** 0.571** 0.362** 0.425** 0.321**
0.672** 0.406** 0.334** 0.172*
0.519** 0.445** 0.250**
0.340** 0.163*
0.521* 0.288**
0.119
PASI, psoriasis area and severity index; PDI, psoriasis disability index; PLSI, psoriasis life stress inventory. *P < 0.05; **P < 0.001.
Table 5 Domains of disability: PDI and clinical severity for low and high stress reactive patients (mean SD)
Domains of PDI
Low stress reactive n = 62
Daily activities Employment Personal relationships Leisure activities Treatment Total PDI PASI
6.19 2.58 1.31 2.89 0.74 13.71 18.75
3.46 2.49 1.51 3.09 0.90 9.7 16.65
High stress reactive n = 139 8.72 4.23 2.19 5.22 1.40 21.76 20.87
3.23 2.33 1.78 3.05 1.00 8.66 12.87
Variable P valuea 0.000 0.000 0.001 0.000 0.000 0.000 NS
NS, not significant; PASI, psoriasis area and severity index; PDI, psoriasis disability index. a t-test.
of the disease was poor. Regardless, our results confirmed that the severity of the disease correlates with impairment of quality of life of patients with psoriasis. According to our results, higher education level of patients with psoriasis was associated with better quality of life. It is known that education empowers individuals by increasing their knowledge and their cognitive, social, and emotional skills. As such, education can help patients to manage their disease better.27 International Journal of Dermatology 2014
Table 6 Results of the multiple linear regression analysis on the psoriasis disability index
PLSI PASI Education
Ba 0.438 0.154 1.399
P value < 0.001 0.001 0.025
PASI, psoriasis area and severity index; PLSI, psoriasis life stress inventory. a Unstandardized regression coefficient.
The family history of psoriasis in our study, similar to the one conducted by Fortune et al.28 did not significantly affect a patient’s quality of life, but the presence of psoriasis within the family was associated with a more severe form of disease, its earlier onset, and higher level of psoriasis-related stress. We also did not find any significant association between age, sex, clinical type or duration of the disease, and quality of life. We found that stress from anticipating other people’s reactions to their psoriasis contributed more to disability in everyday life than any other demographic or clinical variable investigated. Patients whose distribution of scores on the PLSI classified them as reactive to stress associated with psoriasis perceived themselves as more disabled in ª 2014 The International Society of Dermatology
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all areas of everyday life as assessed by PDI (daily activities, employment, personal relationship, leisure, and treatment effects). Our results are in accordance with the previous findings.28,29 Rakhesh et al.26 also found that high stress reactive patients with psoriasis had more overall physical disability in almost all areas of everyday life (except for personal relationships). As it is known that stress can worsen psoriasis,30–32 clinicians should be aware of these findings. When we compared disease severity (PASI scores) of patients who were high stress reactors and of those who were low stress reactors, the small difference found did not reach statistical significance. Our finding is in agreement with the results of Gupta et al.,30 Fortune et al.,28 and Zachariae et al.,29 showing that two groups of reactors did not differ with respect to the usual dermatological criteria of psoriasis severity. However, the opposite results were achieved in several other studies.22,26,33 Our patients reported a higher level of stress due to their body image, loss of self-esteem, and embarrassment regarding their appearance, which is in accordance with the results of other authors.13,26,28 The stress caused by shedding of the skin, feeling self-conscious among strangers, avoiding social contacts, and sunbathing in public places was ranked higher than the stress caused by events in which patients with psoriasis were discriminated by other people. However, unpleasant reactions to changes in the skin of patients with psoriasis are unfortunately a constant occurrence, but patients find a way to avoid this situation or ignore it, to reduce anxiety and stress.34 This behavior may reduce the current sense of stress, but it leads to further reduction in quality of life, due to various restrictions it brings along. The ability to cope with impairments and the availability of social support may indeed affect the quality of life of patients with psoriasis. Some limitations of the current study should be mentioned. First, it was a cross-sectional study, thus making the findings limited. Second, the number of patients studied was relatively small. Finally, investigation of a broad concept such as quality of life may be affected by other possible confounders not considered here. In conclusion, our results suggest that psoriasis exerts significant, negative impact on patients’ quality of life and emphasize the importance of psychological and social factors as predictors of quality of life. The association between clinically assessed severity and quality of life in our study was generally weak. Patients who were classified as more reactive to psoriasis-specific stress experienced significantly more disability in all areas of everyday life. Our results support the importance of assessing the quality of life in psoriasis and effects of stress in patients’ adjustment to their condition and may have important ª 2014 The International Society of Dermatology
Quality of life in psoriasis
Report
implications for psychological stress management in the clinical management of psoriasis. Acknowledgments This work was supported by the Ministry of Education and Science, Republic of Serbia, Project No 175025. We are grateful to Professor Andrew Finlay and Dr. Madhulika Gupta for their formal permission to translate and use the PDI and PLSI questionnaires, respectively. References 1 Gupta MA, Gupta AK. Quality of life of psoriasis patients. J Eur Acad Dermatol Venereol 2000; 14: 241–242. 2 Sampogna F, Chren MM, Melchi CF, et al. Age, gender, quality of life and psychological distress in patients hospitalized with psoriasis. Br J Dermatol 2006; 154: 325–331. 3 Krueger G, Koo J, Lebwohl M, et al. The impact of psoriasis on quality of life: results of a 1998 National Psoriasis Foundation patient-membership survey. Arch Dermatol 2001; 137: 280–284. 4 Bhosle ML, Kulkarni A, Feldman SR, et al. Quality of life in patients with psoriasis. Health Qual Life Outcomes 2006; 4: 35. 5 Jankovic S, Raznatovic M, Marinkovic J, et al. Health-related quality of life in patients with psoriasis. J Cutan Med Surg 2011; 15: 29–36. 6 Palota T, Szepietowski JC, Pec J, et al. A survey of disease severity, quality of life, and treatment patterns of biologically naive patients with psoriasis in Central and Eastern Europe. Acta Dermatovenerol Croat 2010; 18: 151–161. 7 Sampogna F, Gisondi P, Tabolli S, et al. Impairment of sexual life in patients with psoriasis. Dermatology 2007; 214: 144–150. 8 Wahl AK, Gjengedal E, Hanestad BR. The bodily suffering of living with severe psoriasis: in-depth interviews with 22 hospitalized patients with psoriasis patients. Qual Health Res 2002; 12: 250–261. 9 Ermertcan AT, Temeltasß G, Deveci A, et al. Sexual dysfunction in patients with psoriasis. J Dermatol 2006; 33: 772–778. 10 Kurd SK, Troxel AB, Crits-Christoph P, et al. The risk of depression, anxiety, and suicidality in patients with psoriasis. A population-based cohort study. Arch Dermatol 2010; 146: 891–895. 11 Picardi A, Mazzotti E, Pasquini P. Prevalence and correlates of suicidal ideation among patients with skin disease. J Am Acad Dermatol 2006; 54: 420–426. 12 Jankovic S, Raznatovic M, Marinkovic J, et al. Relevance of psychosomatic factors in psoriasis: a case control study. Acta Dermatol Venereol 2009; 89: 364–368. 13 Fortune DG, Richards HL, Griffiths CE. Psychologic factors in psoriasis: consequences mechanisms, and interventions. Dermatol Clin 2005; 23: 681–694. International Journal of Dermatology 2014
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14 Kimball AB, Jacobson C, Weiss S, et al. The psychosocial burden of psoriasis. Am J Clin Dermatol 2005; 6: 383–392. 15 de Arruda LH, De Moraes AP. The impact of psoriasis on quality of life. Br J Dermatol 2001; 144: 33–36. 16 Vardy D, Besser A, Amir M, et al. Experiences of stigmatization play a role in mediating the impact of disease severity on quality of life in psoriasis patients. Br J Dermatol 2002; 147: 736–742. 17 Gelfand JM, Feldman SR, Stern RS, et al. Determinants of quality of life in patients with psoriasis: a study from the US population. J Am Dermatol 2004; 51: 704–708. 18 Esposito M, Sraceno R, Giunta A, et al. An Italian study on psoriasis and depression. Dermatology 2006; 212: 123–127. 19 Richards HL, Fortune DG, Weidmann A, et al. Detection of psychological distress in patients with psoriasis: low consensus between dermatologist and patient. Br J Dermatol 2004; 151: 1227–1233. 20 Fredricksson T, Petterson U. Severe psoriasis: oral therapy with a new retinoid. Dermatologica 1978; 157: 238–244. 21 Finlay AY, Kelly SE. Psoriasis: an index of disability. Clin Exp Dermatol 1987; 12: 8–11. 22 Gupta MA, Gupta AK. The psoriasis life stress inventory: a preliminary index of psoriasis related stress. Acta Derm Venereol (Stockh) 1995; 75: 240–243. 23 Misery L, Thomas L, Jullien D, et al. Comparative study of stress and quality of life in outpatients consulting for different dermatoses in 5 academic departments of dermatology. Eur J Dermatol 2008; 18: 412–415. 24 de Korte J, Sprangers MA, Mombers FM, et al. Quality of life in patients with psoriasis: a systematic literature review. J Investig Dermatol Symp Proc 2004; 9: 140–147.
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25 Ashcroft DM, Li Wan Po A, Williams HC, et al. Quality of life measures in psoriasis: a critical appraisal of their quality. J Clin Pharm Ther 1998; 23: 391–398. 26 Rakhesh SV, DSouza M, Sahai A. Quality of life in psoriasis: a study from south India. Indian J Dermatol Venereol Leprol 2008; 74: 600–606. 27 Ross CE. Education and the subjective quality of life. J Health Soc Behav 1997; 38: 275–297. 28 Fortune DG, Main CJ, O’Sullivan TM, et al. Quality of life in patients with psoriasis: the contribution of clinical variables and psoriasis specific stress. Br J Dermatol 1997; 137: 755–760. 29 Zachariae R, Zachariae H, Blomqvist K, et al. Self-reported stress reactivity and psoriasis-related stress of Nordic psoriasis sufferers. J Eur Acad Dermatol Venereol 2004; 18: 27–36. 30 Gupta AM, Gupta AK, Kirkby S. A psychocutaneous profile of psoriasis patients who are stress reactors. A study of 127 patients. Gen Hosp Psychiatry 1989; 11: 163–173. 31 Schmid-Ott G, Jaeger B, Boehm T, et al. Immunological effects of stress in psoriasis. Br J Dermatol 2009; 160: 782–785. 32 O’Leary CJ, Creamer D, Higgins E, et al. Perceived stress, stress attributions and psychological distress in psoriasis. J Psychosom Res 2004; 57: 465–471. 33 Sampogna F, Sera F, Abeni D, et al. Measures of clinical severity, quality of life, and psychological distress in patients with psoriasis: a cluster analysis. J Invest Dermatol 2004; 122: 602–607. 34 Finlay AY, Coles EC. The effect of severe psoriasis on the quality of life of 369 patients. Br J Dermatol 1995; 132: 236–244.
ª 2014 The International Society of Dermatology
Assessment of quality of life in patients with psoriasis: a study from Serbia Danijela Milcic1, MD, MSc, Slavenka Jankovic2, MD, PhD, Sonja Vesic1, MD, PhD, Mirjana Milinkovic1, MD, PhD, and Janko Jankovic3, MD, PhD
1 Institute of Dermatovenereology, Clinical Center of Serbia and Faculty of Medicine Institutes of 2 Epidemiology and 3 Social Medicine, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
Abstract Background Psoriasis has a substantial impact on patients’ quality of life. Objectives The aims of this study were to assess the impact of the clinical severity of psoriasis on patients’ quality of life and to determine the effects of psoriasis-related stress on patients’ everyday life.
Correspondence Danijela Mil ci c, MD, MSC Clinical Center of Serbia Institute of Dermatovenereology Pasterova 2 11000 Belgrade Serbia E-mail: [email protected] Conflicts of interest: None. doi: 10.1111/ijd.12391
Methods The cross-sectional study was conducted at the Institute of Dermatovenereology, Clinical Center of Serbia, Belgrade. The study included 201 patients (124 men and 77 women), aged 18–70 with a diagnosis of psoriasis, hospitalized or treated as outpatients during 2009. For the assessment of patients’ quality of life, the psoriasis disability index (PDI) was used. The stress related to psoriasis was measured with the psoriasis life stress inventory (PLSI) and disease severity with the psoriasis area and severity index (PASI). Results We found moderate correlation between PLSI and all PDI subscales and overall score (correlation coefficients ranged from 0.334 to 0.521). The correlation between PASI and PDI subscales was weak, while we failed to find any significant correlation between PASI and the PLSI. The results of multiple regression analysis indicated that stress, more severe disease, and lower educational level are significant determining factors of a poorer quality of life in patients with psoriasis. Conclusion Our results support the importance of assessing the quality of life in psoriasis and effects of stress in patients’ adjustment to their condition and may have important implications for a psychological stress management approach in the clinical management of psoriasis.
Introduction Psoriasis is an immune-mediated inflammatory skin disease with complex pathogenesis. It is a chronic, genetically determined disease, characterized by different clinical manifestations and unpredictable course. Generally psoriasis is not a life-threatening disease but has a profound negative impact on a patient’s quality of life.1–3 Although psoriasis affects approximately 2% of the world’s population,4 very few studies examined quality of life in patients with psoriasis in southeastern European.5,6 World-wide, it is well known that patients with psoriasis have difficulties in their daily activities, and occupational and sexual functioning.7–9 In addition, patients with psoriasis, significantly more frequently than the general population, have various psychiatric disorders, such as depression, anxiety, social isolation, even suicidal ideation.3,10–12 Owing to the visibility of skin lesions, patients may feel humiliated and embarrassed, and the chronic and recurring nature of the disease makes them ª 2014 The International Society of Dermatology
feel helpless.13–15 High levels of stress may be associated with worsening of the disease and lack of appropriate therapeutic response.16 Negative impact of psoriasis on a patient’s quality of life has been demonstrated in a number of studies, and its correlation with the demographic and clinical disease characteristics varies.5,17,18 Researchers have indicated that 30–40% of patients with psoriasis suffer significant psychological distress related to their disease.19 The aims of this study were to assess the impact of psoriasis (especially its clinical severity) on patients’ quality of life, and to investigate the effects of perceptions of psoriasisrelated stress on areas of disability in everyday life. Methods Patients A cross-sectional study was carried out at the Institute of Dermatovenereology, Clinical Center of Serbia (Belgrade), during 2009. The study group consisted of 201 consecutive International Journal of Dermatology 2014
1
2
Report
ic et al. Milc
Quality of life in psoriasis
patients with psoriasis, of both sexes, aged 18–70 years, with duration of the disease of at least three months before the
The validated and cross-culturally adapted Serbian versions of the used questionnaires showed good internal reliability across
examination. All patients were in the exacerbation stage of
scales (Cronbach’ s alpha was 0.84 for PDI and 0.78 for PLSI).
psoriasis. The majority of them (71%) required hospital admission while ambulatory patients accounted for a smaller part of the study group (29%). None of the patients has been treated with systemic therapy before examination. The study protocol was approved by the Ethics Committee of the Clinical Center of Serbia, Belgrade, and written informed consent was obtained from all participants.
Instruments A short standardized form was used to collect data regarding age, sex, education, duration of psoriasis, age at onset, and family history of psoriasis. Diagnosis of psoriasis was confirmed by experienced dermatologists. The psoriasis area and severity index (PASI) was used for the assessment of the disease severity.20 The PASI score is obtained as a result of evaluation of erythema, infiltration, desquamation, and area of the skin involved by psoriasis. It can vary from 0 (the lowest score) to 72 (the highest score) with higher scores indicating greater severity. In our study, mild psoriasis was classified as a PASI 25. To date, no consensus has been reached on the cut-off levels for the PASI. The reason that we used the above-mentioned cut-off values is that our study was carried out in the large tertiary care hospital (Institute of Dermatology, Clinical Center of Serbia) where serious skin conditions and illnesses are often cared for. If we used lower cut-off values as in most studies, the majority of our patients would be in one group – the group of patients with severe psoriasis – without a possibility for comparison. To evaluate the impact of psoriasis on the patients’ quality of life, we used the psoriasis disability index (PDI), a 15-item scale related to daily activities, work or school, personal relationships, leisure, and treatment effects.21 All the questions referred to events that had taken place in the preceding four weeks. The answers were scored from 0 to 3 (0, “not at all”; 1, “a little”; 2, “a lot”; 3,“very much”), producing a range of total PDI score from 0 to 45. The higher the score, the more quality of life is impaired. The 15-item version of the psoriasis life stress inventory (PLSI) was used to measure stress associated with having to cope with everyday events in living with psoriasis.22 For each item, patients were asked to rate the level of stress experienced over the previous four weeks on a four-point scale, from “not at all” to “a great deal”. According to the results of the total PLSI score (ranged from 0 to 45), patients were classified into two groups: high stress reactors (patients who reacted significantly to the stress associated with having psoriasis [score of ≥10]), and low stress reactors (patients who were not significantly affected by psoriasis-related stress [score of 25, n (%)
124 (61.7) 77 (38.3) 55 (27.4) 112 (55.7) 15 (7.5) 19 (9.5) 50.79 13.26 3.99 2.03 46.96 13.20 61 (30.3) 140 (69.7) 94 (46.8) 71 (35.3) 26 (12.9) 10 (5.0) 20.2 14.1 63 (31.3) 83 (41.3) 55 (27.4)
Table 2 Scores for demographic, clinical and quality of life variables in patients with psoriasis as a function of their family history of psoriasis (mean SD) Family history of psoriasis Variable
No (n = 140)
Age Duration of psoriasis Age at onset PASI PDI PLSI
52.41 3.73 48.69 19.13 19.04 14.84
12.69 2.11 12.78 13.29 9.59 11.05
Yes (n = 61) 47.57 4.57 43.00 22.70 19.82 18.46
13.62 1.69 13.39 15.75 10.06 10.54
P valuea 0.016 0.000 0.005 0.030 NS 0.032
NS, not significant; PASI, psoriasis area and severity index; PDI, psoriasis disability index; PLSI, psoriasis life stress inventory. a t-test.
not found for personal relationships and treatment related effects. The relationship between quality of life measures (PDI, PLSI) and PASI, expressed by Pearson correlation coefficients, is shown on Table 4. We found moderate correlation between PLSI and all PDI subscales and overall score (correlation coefficients ranged from 0.334 to 0.521). The correlation between clinical severity of psoriasis (PASI) and PDI subscales was weak, although statistically significant (correlation ª 2014 The International Society of Dermatology
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coefficients were between 0.163 and 0.321), while we failed to find any significant correlation between PASI and the PLSI. Patients whose distribution on the PLSI classified them as highly reactive to stress associated with psoriasis (score ≥10) in comparison with low stress reactive patients (score 25 n = 55
PASI (12–25) n = 83
3.45 2.20 1.71 3.12 0.93 11.17
8.48 3.96 2.06 4.73 1.20 20.43
3.32 2.43 1.64 3.47 1.00 9.57
8.74 4.64 2.14 5.37 1.40 22.29
P valuea
3.37 2.47 1.89 2.70 1.12 8.83
0.000 0.000 0.108 0.005 0.145 0.000
QoL, quality of life; PASI, psoriasis area and severity index; PDI, psoriasis disability index. a ANOVA. Table 4 Pearson correlation coefficients for relations between PDI, PLSI, and PASI
Employment Personal relationships Leisure Treatment PLSI PASI
Daily activities
Employment
Personal relationships
Leisure activities
Treatment effects
PDI (total score)
PLSI
0.703** 0.467** 0.543** 0.430** 0.462** 0.206**
0.532** 0.571** 0.362** 0.425** 0.321**
0.672** 0.406** 0.334** 0.172*
0.519** 0.445** 0.250**
0.340** 0.163*
0.521* 0.288**
0.119
PASI, psoriasis area and severity index; PDI, psoriasis disability index; PLSI, psoriasis life stress inventory. *P < 0.05; **P < 0.001.
Table 5 Domains of disability: PDI and clinical severity for low and high stress reactive patients (mean SD)
Domains of PDI
Low stress reactive n = 62
Daily activities Employment Personal relationships Leisure activities Treatment Total PDI PASI
6.19 2.58 1.31 2.89 0.74 13.71 18.75
3.46 2.49 1.51 3.09 0.90 9.7 16.65
High stress reactive n = 139 8.72 4.23 2.19 5.22 1.40 21.76 20.87
3.23 2.33 1.78 3.05 1.00 8.66 12.87
Variable P valuea 0.000 0.000 0.001 0.000 0.000 0.000 NS
NS, not significant; PASI, psoriasis area and severity index; PDI, psoriasis disability index. a t-test.
of the disease was poor. Regardless, our results confirmed that the severity of the disease correlates with impairment of quality of life of patients with psoriasis. According to our results, higher education level of patients with psoriasis was associated with better quality of life. It is known that education empowers individuals by increasing their knowledge and their cognitive, social, and emotional skills. As such, education can help patients to manage their disease better.27 International Journal of Dermatology 2014
Table 6 Results of the multiple linear regression analysis on the psoriasis disability index
PLSI PASI Education
Ba 0.438 0.154 1.399
P value < 0.001 0.001 0.025
PASI, psoriasis area and severity index; PLSI, psoriasis life stress inventory. a Unstandardized regression coefficient.
The family history of psoriasis in our study, similar to the one conducted by Fortune et al.28 did not significantly affect a patient’s quality of life, but the presence of psoriasis within the family was associated with a more severe form of disease, its earlier onset, and higher level of psoriasis-related stress. We also did not find any significant association between age, sex, clinical type or duration of the disease, and quality of life. We found that stress from anticipating other people’s reactions to their psoriasis contributed more to disability in everyday life than any other demographic or clinical variable investigated. Patients whose distribution of scores on the PLSI classified them as reactive to stress associated with psoriasis perceived themselves as more disabled in ª 2014 The International Society of Dermatology
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all areas of everyday life as assessed by PDI (daily activities, employment, personal relationship, leisure, and treatment effects). Our results are in accordance with the previous findings.28,29 Rakhesh et al.26 also found that high stress reactive patients with psoriasis had more overall physical disability in almost all areas of everyday life (except for personal relationships). As it is known that stress can worsen psoriasis,30–32 clinicians should be aware of these findings. When we compared disease severity (PASI scores) of patients who were high stress reactors and of those who were low stress reactors, the small difference found did not reach statistical significance. Our finding is in agreement with the results of Gupta et al.,30 Fortune et al.,28 and Zachariae et al.,29 showing that two groups of reactors did not differ with respect to the usual dermatological criteria of psoriasis severity. However, the opposite results were achieved in several other studies.22,26,33 Our patients reported a higher level of stress due to their body image, loss of self-esteem, and embarrassment regarding their appearance, which is in accordance with the results of other authors.13,26,28 The stress caused by shedding of the skin, feeling self-conscious among strangers, avoiding social contacts, and sunbathing in public places was ranked higher than the stress caused by events in which patients with psoriasis were discriminated by other people. However, unpleasant reactions to changes in the skin of patients with psoriasis are unfortunately a constant occurrence, but patients find a way to avoid this situation or ignore it, to reduce anxiety and stress.34 This behavior may reduce the current sense of stress, but it leads to further reduction in quality of life, due to various restrictions it brings along. The ability to cope with impairments and the availability of social support may indeed affect the quality of life of patients with psoriasis. Some limitations of the current study should be mentioned. First, it was a cross-sectional study, thus making the findings limited. Second, the number of patients studied was relatively small. Finally, investigation of a broad concept such as quality of life may be affected by other possible confounders not considered here. In conclusion, our results suggest that psoriasis exerts significant, negative impact on patients’ quality of life and emphasize the importance of psychological and social factors as predictors of quality of life. The association between clinically assessed severity and quality of life in our study was generally weak. Patients who were classified as more reactive to psoriasis-specific stress experienced significantly more disability in all areas of everyday life. Our results support the importance of assessing the quality of life in psoriasis and effects of stress in patients’ adjustment to their condition and may have important ª 2014 The International Society of Dermatology
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implications for psychological stress management in the clinical management of psoriasis. Acknowledgments This work was supported by the Ministry of Education and Science, Republic of Serbia, Project No 175025. We are grateful to Professor Andrew Finlay and Dr. Madhulika Gupta for their formal permission to translate and use the PDI and PLSI questionnaires, respectively. References 1 Gupta MA, Gupta AK. Quality of life of psoriasis patients. J Eur Acad Dermatol Venereol 2000; 14: 241–242. 2 Sampogna F, Chren MM, Melchi CF, et al. Age, gender, quality of life and psychological distress in patients hospitalized with psoriasis. Br J Dermatol 2006; 154: 325–331. 3 Krueger G, Koo J, Lebwohl M, et al. The impact of psoriasis on quality of life: results of a 1998 National Psoriasis Foundation patient-membership survey. Arch Dermatol 2001; 137: 280–284. 4 Bhosle ML, Kulkarni A, Feldman SR, et al. Quality of life in patients with psoriasis. Health Qual Life Outcomes 2006; 4: 35. 5 Jankovic S, Raznatovic M, Marinkovic J, et al. Health-related quality of life in patients with psoriasis. J Cutan Med Surg 2011; 15: 29–36. 6 Palota T, Szepietowski JC, Pec J, et al. A survey of disease severity, quality of life, and treatment patterns of biologically naive patients with psoriasis in Central and Eastern Europe. Acta Dermatovenerol Croat 2010; 18: 151–161. 7 Sampogna F, Gisondi P, Tabolli S, et al. Impairment of sexual life in patients with psoriasis. Dermatology 2007; 214: 144–150. 8 Wahl AK, Gjengedal E, Hanestad BR. The bodily suffering of living with severe psoriasis: in-depth interviews with 22 hospitalized patients with psoriasis patients. Qual Health Res 2002; 12: 250–261. 9 Ermertcan AT, Temeltasß G, Deveci A, et al. Sexual dysfunction in patients with psoriasis. J Dermatol 2006; 33: 772–778. 10 Kurd SK, Troxel AB, Crits-Christoph P, et al. The risk of depression, anxiety, and suicidality in patients with psoriasis. A population-based cohort study. Arch Dermatol 2010; 146: 891–895. 11 Picardi A, Mazzotti E, Pasquini P. Prevalence and correlates of suicidal ideation among patients with skin disease. J Am Acad Dermatol 2006; 54: 420–426. 12 Jankovic S, Raznatovic M, Marinkovic J, et al. Relevance of psychosomatic factors in psoriasis: a case control study. Acta Dermatol Venereol 2009; 89: 364–368. 13 Fortune DG, Richards HL, Griffiths CE. Psychologic factors in psoriasis: consequences mechanisms, and interventions. Dermatol Clin 2005; 23: 681–694. International Journal of Dermatology 2014
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14 Kimball AB, Jacobson C, Weiss S, et al. The psychosocial burden of psoriasis. Am J Clin Dermatol 2005; 6: 383–392. 15 de Arruda LH, De Moraes AP. The impact of psoriasis on quality of life. Br J Dermatol 2001; 144: 33–36. 16 Vardy D, Besser A, Amir M, et al. Experiences of stigmatization play a role in mediating the impact of disease severity on quality of life in psoriasis patients. Br J Dermatol 2002; 147: 736–742. 17 Gelfand JM, Feldman SR, Stern RS, et al. Determinants of quality of life in patients with psoriasis: a study from the US population. J Am Dermatol 2004; 51: 704–708. 18 Esposito M, Sraceno R, Giunta A, et al. An Italian study on psoriasis and depression. Dermatology 2006; 212: 123–127. 19 Richards HL, Fortune DG, Weidmann A, et al. Detection of psychological distress in patients with psoriasis: low consensus between dermatologist and patient. Br J Dermatol 2004; 151: 1227–1233. 20 Fredricksson T, Petterson U. Severe psoriasis: oral therapy with a new retinoid. Dermatologica 1978; 157: 238–244. 21 Finlay AY, Kelly SE. Psoriasis: an index of disability. Clin Exp Dermatol 1987; 12: 8–11. 22 Gupta MA, Gupta AK. The psoriasis life stress inventory: a preliminary index of psoriasis related stress. Acta Derm Venereol (Stockh) 1995; 75: 240–243. 23 Misery L, Thomas L, Jullien D, et al. Comparative study of stress and quality of life in outpatients consulting for different dermatoses in 5 academic departments of dermatology. Eur J Dermatol 2008; 18: 412–415. 24 de Korte J, Sprangers MA, Mombers FM, et al. Quality of life in patients with psoriasis: a systematic literature review. J Investig Dermatol Symp Proc 2004; 9: 140–147.
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25 Ashcroft DM, Li Wan Po A, Williams HC, et al. Quality of life measures in psoriasis: a critical appraisal of their quality. J Clin Pharm Ther 1998; 23: 391–398. 26 Rakhesh SV, DSouza M, Sahai A. Quality of life in psoriasis: a study from south India. Indian J Dermatol Venereol Leprol 2008; 74: 600–606. 27 Ross CE. Education and the subjective quality of life. J Health Soc Behav 1997; 38: 275–297. 28 Fortune DG, Main CJ, O’Sullivan TM, et al. Quality of life in patients with psoriasis: the contribution of clinical variables and psoriasis specific stress. Br J Dermatol 1997; 137: 755–760. 29 Zachariae R, Zachariae H, Blomqvist K, et al. Self-reported stress reactivity and psoriasis-related stress of Nordic psoriasis sufferers. J Eur Acad Dermatol Venereol 2004; 18: 27–36. 30 Gupta AM, Gupta AK, Kirkby S. A psychocutaneous profile of psoriasis patients who are stress reactors. A study of 127 patients. Gen Hosp Psychiatry 1989; 11: 163–173. 31 Schmid-Ott G, Jaeger B, Boehm T, et al. Immunological effects of stress in psoriasis. Br J Dermatol 2009; 160: 782–785. 32 O’Leary CJ, Creamer D, Higgins E, et al. Perceived stress, stress attributions and psychological distress in psoriasis. J Psychosom Res 2004; 57: 465–471. 33 Sampogna F, Sera F, Abeni D, et al. Measures of clinical severity, quality of life, and psychological distress in patients with psoriasis: a cluster analysis. J Invest Dermatol 2004; 122: 602–607. 34 Finlay AY, Coles EC. The effect of severe psoriasis on the quality of life of 369 patients. Br J Dermatol 1995; 132: 236–244.
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