Psoriasis and the psyche

Psoriasis, a chronic skin disorder which produces papulo-squamous rash,1 has a considerable psychological impact.2 It reduces mental and physical functioning to a similar extent to other chronic conditions including arthritis, cancer, depression and heart disease.2 Treatment has a positive impact not only on psoriatic skin lesions, but also on health-related quality of life,3 and improving psychological outcomes is important for increasing treatment compliance.4 When developing an individualised treatment plan for each psoriasis patient, cognisance of the links between physical symptoms, treatments, treatment compliance and psychological outcomes will maximise the effectiveness of therapy.5,6

How psoriasis influences quality of life
Psoriatic skin lesions cause physical discomfort, itching and burning sensations.⁷ However, Melbourne University Professor Rodney Sinclair, a consultant dermatologist at Epworth Specialist Centre believes that, “the biggest issue for people with psoriasis is a feeling of embarrassment.” The condition causes a change in the appearance of skin, which develops a red and scaly rash that may be misinterpreted as a symptom of another disease. In one study, more than half the participants reported others had thought their psoriatic lesions were a symptom of a contagious disease and about one in ten reported others thought their rash a symptom of acquired immune deficiency syndrome (AIDS).⁷

The highly visible symptoms of skin conditions like psoriasis means they are likely to be associated with negative psychological outcomes.² Patients < 55 years are the most likely to have poor psychological outcomes as a result of the disease.⁷ Those with affected skin on sites which are commonly exposed like the hands and face are particularly likely to be distressed about their condition.²

Sports and social avoidance
Patients with psoriasis often avoid exposing their skin which can interfere with their participation in social events³ and sports.⁸ “A person suffering from psoriasis may end up withdrawing from social activities to avoid potential embarrassment,” explained Professor Sinclair. “Psoriasis sufferers often avoid sports changing rooms or wearing short sleeved or short legged clothing.” They may also have difficulty accessing sporting facilities. For example, in one study 7% of participants reported being denied entry to public facilities including gymnasiums and swimming pools and 40% reported trouble receiving equal treatment at these facilities.⁷

Relationships
Patients report feeling physically and sexually unattractive,² and having difficulty establishing and maintaining relationships with family members, friends and intimate partners.⁷ Professor Sinclair says that, “initiating new relationships can be very difficult especially when revealing the condition to a new person may lead to rejection.” Sexual activity is also often affected by psoriasis; 27% of patients ≤ 54 years report the condition negatively affects their sex life.⁷

Work and economic opportunity
Psoriasis also has a negative impact on workplace relationships as well as a negative economic impact. Patients report discrimination at work and difficulty interacting with their colleagues.⁷ Finding a job may be more difficult and when work is found psoriasis may impair workplace functioning and career development.² It is the cause of an average of 2.3 days sick leave per patient per year,⁷ and one study attributed 40% of the cost of psoriasis (US$11.25 billion per annum in the United States) to workplace absenteeism.⁹

Daily functioning
Psoriasis also causes functional impairment, particularly in those with affected hands and feet and/or comorbid psoriatic arthritis. Sleep is impaired in > 20% of patients. Walking, sitting, standing and using the hands is difficult for a significant minority of psoriasis patients and the majority of those with comorbid arthritis. The considerable time (26 minutes per day) needed to apply topical treatment can also interfere with daily activities.⁷

Psychological outcomes in psoriasis patients
Psoriasis has a considerable negative impact on quality of life and is associated with poor psychological outcomes and a greatly increased risk of suicide.² The majority of patients aged 18–34 years report feeling embarrassed about their skin (81%) and unattractive (75%). An even greater proportion (88%) are concerned about the future and the potential for skin symptoms to worsen. 10% report having contemplated suicide.⁷

Managing psoriasis patients
The psychological and quality of life impact of psoriasis are important factors to consider when developing an individualised management plan for psoriasis patients. The plan should include preventive and curative treatments, and consider the impact of the disease and treatments on the patient’s quality of life and psychological health, as well as the ways in which psychological health influences treatment compliance.^5,6

Preventing psoriasis
Psoriasis is an incurable disease, but patients can take measures to prevent or reduce the severity of symptom outbreaks.¹⁰ “Preventative measures for psoriasis fall into two categories: Using things that help; and avoiding things that make psoriasis worse,” says Professor Sinclair.

Things that help
While many psoriasis patients are reluctant to expose their skin, UV radiation is an effective treatment for psoriatic lesions.⁵ “Sunlight and salt water help psoriasis,” says Professor Sinclair. “A winter holiday in far north Queensland each year can make a huge difference.  International resorts like the Dead Sea in Israel are famous for their healing effects on psoriasis.” 

Conditions associated with unhealthy diet, including type 2 diabetes, metabolic syndrome and obesity are associated with an increased risk of psoriasis.¹¹  Eating a balanced diet and performing regular physical activity reduces the risk of these conditions and are important lifestyle measures for general health.¹² However, exercise can be more difficult for people with psoriasis who may avoid sports as a way of avoiding skin exposure.⁸ Professor Sinclair notes that one of the consequences of sports-avoidance is that “obesity is common in people with psoriasis and this can have its own psychosocial impact.” There is evidence that the likelihood of obesity and diabetes increases with increasing severity of psoriasis.¹³

“Unfortunately, there is no specific diet that helps psoriasis.” However, Professor Sinclair noted that patients who “have found that a particular food makes [their] psoriasis better should continue to eat it.”

Things to avoid
Smoking is associated with a 1.3 times increased odds ratio of severe psoriasis and is a key modifiable risk factor.¹³ Evidence for alcohol consumption is conflicting; however, alcohol affects most body systems including the skin and its consumption is also associated with poor psychological outcomes in psoriasis patients and poor treatment compliance.¹⁴ Both alcohol¹⁴ and the nicotine¹⁵ in cigarettes are addictive and patients may need support and assistance to reduce alcohol and/or tobacco consumption.¹⁴

Emotional stress can be a trigger for psoriasis and up to 60% of patients experience stressful life events in the months before acute exacerbations of psoriasis.¹⁴ Stress reduction techniques are therefore important for psoriasis patients although the appropriate techniques will vary depending on the source of stress.² For some patients it may be important to identify and resolve conflicts at work or at home.¹⁶ For others, learning to deal with stress when it occurs, for example using controlled breathing or muscle relaxation exercises might be the best strategy.²

“Certain medications… can exacerbate psoriasis and should be avoided where possible,” Professor Sinclair said. They include prescription drugs like lithium, anti-malarials and beta blockers.¹⁴ “Even common over-the-counter medications such as aspirin and non-steroidal anti-inflammatory drugs can make psoriasis worse,” continued Professor Sinclair. Rapid withdrawal of corticosteroid medications is also associated with worsening psoriasis. Assessing, and where possible altering medication use is also an important component of preventing the acute symptoms of psoriasis.¹⁴

Determining a treatment plan
Good patient-provider communication is a key factor in achieving patient satisfaction with treatment,⁷ and addressing patient priorities.¹⁷ Patients may be just as concerned about making treatment convenient and improving quality of life as they are about controlling skin lesions.¹⁷ The quality of life effects of psoriasis are of key importance when determining the best course of treatment.⁷ Professor Sinclair says that psoriasis treatment should, “match the impact that the disease is having on quality of life. A severe impact may warrant more aggressive treatments.”

Practitioners must be cognisant that there is poor correlation between the physical and psychological symptoms of psoriasis. Patients with relatively severe psoriatic lesions may have better psychological health than those with mild-moderate symptoms.⁷ Patients diagnosed later in life tend to have more severe psychological symptoms, as do those with alcohol dependence disorder.¹⁴

The incurable nature of the disease,² as well as the significant morbidity associated with it must be carefully explained to ensure patients understand the long-term implications and consider the risks and benefits of various treatments in this framework.¹⁰ Patients often underestimate the severity of their skin lesions and are likely to underestimate the psychological effects of the disease as well.⁷

Treatment options
There are numerous treatment options and the recent development of biologically targeted drugs in the treatment of psoriasis has provided further options for severe psoriasis patients. When psoriasis is mild, monotherapy with topical creams and gels is typically sufficient to control skin lesions.⁵ They are safe and effective but practitioners should be aware that the application of topical treatments takes an average of 26 minutes per day and can impair other daily activities.⁷ Treatment compliance is increased when preparations are used that are easier to apply and less messy.¹¹

Topicals play an important role in reducing the dose of systemic therapies in more severe cases, however, alone are usually insufficient to treat severe disease.⁷ More aggressive therapies include phototherapy, systemic corticosteroids (cyclosporine),⁵ folic acid antagonists (methotrexate),⁷ or retinols (acitretin), and new age biological agents.⁵ Biological treatments are highly effective. However, they are expensive⁵ and in Australia are only available through the Pharmaceutical Benefits Scheme to patients who have failed to respond to phototherapy and systemic agents.¹⁸

When deciding which therapy to use, practitioners should consider how the frequency and inconvenience of treatment as well as the side effects, will affect a patient’s quality of life and psychological health.^7,17,19 Both systemic and phototherapies have severe side effects which can be dose limiting.¹⁸ Phototherapy is also inconvenient because it must be administered in a clinical setting. ⁵ Some systemic therapies require inpatient administration and inpatient treatment of psoriasis is associated with reduced quality of life in the short-term.³

Using systemic treatments or phototherapy in combination with topical therapies is one strategy which can reduce the side effects and their potential impact on quality of life.⁷ While biological agents have a favourable side effect profile and require infrequent administration, their high expense⁵ may compound the financial difficulties of psoriasis patients who have difficulty finding work and progressing in their careers.⁷

Treatment for healthy skin and a healthy psyche
Practitioners treating psoriasis must consider both the skin symptoms and the psychological impact of the disease.⁵ Patients’ physical responses to treatment differ, as do their psychological responses to the skin symptoms of psoriasis.² However, a wide range of treatment options exist and the right combination of treatments does more than relieve the skin symptoms of the disease. Effective treatment also improves health-related quality of life.³

This approach to treatment is exemplified by Professor Sinclair’s belief that the most effective psoriasis treatment “manages the patient, not just the psoriasis.”

References

1. Griffiths CE, Barker JN. Pathogenesis and clinical features of psoriasis. Lancet. 2007; 370(9583): 263-71. [Abstract]
2. Barankin B DeKoven J. Psychosocial effects of common skin disorders. Can Fam Phys. 2002; 48: 712-8. [Abstract | Full Text]
3. Prins M, Krabbe PFM, Swinkels QOJ, et al. The Effect of Treatment on Quality of Life in Psoriasis Patients. Acta Derm Venereol. 2005; 85: 304–310. [Full Text]
4. Weiss SC, Bergstrom KG, Weiss SA, et al. Quality of life considerations in psoriasis treatment. Dermatol Nurs. 2003; 15(2): 123-7. [Abstract]
5. Herrier RN. Advances in the treatment of moderate-severe psoriasis. Am J Health Sys Pharm. 2011; 68: 795-806. [Abstract]
6. Foulkes AC, Grindlay DJC, Griffiths CEM, et al. What’s new in psoriasis? An analysis of guidelines and systematic reviews published in 2009-10. Clin Experimental Dermatol. 2011; 36: 585-9. [Abstract | Full text]
7. 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(3): 280-4. [Abstract | Full text]
8. Ramsey B, O’Reagan M. A survey of the social and psychological effects of psoriasis. Br J Dermatol. 1988; 118(2): 195-201. [Abstract]
9. Langham S, Langham J, Goertz H, Ratcliffe M. Large-scale, prospective, observational studies in patients with psoriasis and psoriatic arthritis: A systematic and critical review. BMC Medical Research Methodology. 2011; 11: 32. [Abstract | Full Text]
10. Murphy G, Reich K. In touch with psoriasis: topical treatments and current guidelines. J Eu Acad Dermatol Venereol. 2011; 25(S4): 3-8. [Abstract | Full text]
11. Traub M, Marshal K. Psoriasis- Pathophysiology, conventional and alternative approaches to treatment. Alt Med Rev. 2007; 12(4): 319-31. [Abstract | Full Text]
12. Esposito K, Ciotola M, Maiorino MI, et al. Lifestyle approach for type 2 diabetes and metabolic syndrome. Cur Atheroschlerosis Rep. 2008; 10(6): 523-8. [Abstract]
13. Neimann AL, Shin DB, Wang X, et al. Prevalence of cardiovascular risk factors in patients with psoriasis. J Am Acad Dermatol. 2006; 55(5): 829-35. [Abstract]
14. Dediol I, Buljan M, Buljan D, et al. Associations of psoriasis and alcoholism: psychodermatological issues. Psychiatria Danube. 2009; 21(1): 9-13. [Abstract | Full Text]
15. Background brief: What’s in cigarettes [online].Quit 2003 [cited July 2010]. Available from URL: [URL Link]
16. Beyond Blue. Fact Sheet 6: Reducing stress. 2010. [cited 22 September 2012]. Available from: [URL Link]
17. Merideth F, Ormerod AD. Patient preferences for psoriasis treatment: process characteristics considered more important than outcome attributes. Exp Rev Pharmacoecon Outcomes Res. 2012; 12(2): 145-7. [Abstract | Full Text]
18. Sullivan R, Preda V. Treatments for severe psoriasis. Australian Prescriber. 2009; 32: 14-18. [Full Text]
19. Chuh A, Wong W, Zawar V. The skin and the mind. Aust Fam Phys. 2006; 35(9): 723-5. [Full Text]