InTechOpen uses cookies to offer you the best online experience. By continuing to use our site, you agree to our Privacy Policy.

Medicine » Dermatology » "Psoriasis - Types, Causes and Medication", book edited by Hermenio Lima, ISBN 978-953-51-1065-1, Published: April 17, 2013 under CC BY 3.0 license. © The Author(s).

Chapter 7

Quality of Life in Psoriasis

By Delia Colombo and Renata Perego
DOI: 10.5772/53998

Article top

Quality of Life in Psoriasis

Delia Colombo1 and Renata Perego1

1. Introduction

Psoriasis has a profound impact on patients’ everyday life. The burden of the disease extends beyond physical manifestations and includes significant physical, social and psychological impairment. Numerous studies have demonstrated the significant negative impact of psoriasis on quality of life (QoL) [1-5]. Furthermore, as a chronic disease, psoriasis affects the QoL of both patients and their close relatives in a cumulative way [6]. The family members of patients with psoriasis experience a wide range of detrimental effects on their lives with regards to psychological social and lifestyle modifications, interpersonal relationships, financial issues, family activities, sleep and issues related to the practical care of the patients.

Various factors may contribute to the lower QoL of patients with psoriasis. The chronic nature of the disease and the lack of control over unexpected outbreaks of the symptoms are among the most bothersome aspects of psoriasis [7]. Patients may feel humiliated when they need to expose their bodies during intimate relationships, swimming, using public showers, or anyway living in conditions that do not provide adequate privacy [8]. Thus psoriasis affects patients’ social life, daily activities, and sexual functioning [9]. Treatment of psoriasis, as it may be associated with risk for adverse effects, is also an important component of the QoL of psoriasis patients [10]. By utilizing the Short Form-36 (SF-3 6), a generic QoL instrument, it has been demonstrated that psoriasis may cause as much disability as other major medical diseases, including heart disease, diabetes, and cancer [11].

Psoriasis is also related to several co-morbidities, especially cardiovascular diseases and psychiatric disorders. Moreover, cardiovascular risk factors are strongly associated with the severity of inflammation and the duration of disease [12-14].

Improving the QoL in psoriasis patients is an extremely important goal. Therefore, the interventions to improve the process of care of this population should also assess QoL outcomes, such as social functioning and emotional well-being, adjusting for the effects of co-existing chronic conditions. Disease-specific measures may be sensitive enough to detect and quantify small changes that are important to clinicians and patients [15]. Healthcare professionals have a crucial role in identifying and supporting affected patients and families. In order to establish a good relationship with family members and to be able to improve patients’ compliance, dermatologists should develop greater insight into the lives of psoriasis patients and their relatives.

In this chapter, the impact of the different aspects of psoriasis on QoL will be reviewed.

2. Skin symptoms

Research found that large percentages of patients with psoriasis reported considerably skin pain and discomfort [16,17]. Skin pain was reported by up to 42%, and skin discomfort by up to 37% of psoriasis patients [16, 18,19]. Skin pain and discomfort had a negative impact on functions such as sleep, mood and enjoyment of life [16]. Studies suggested that other psoriasis-related sensory skin symptoms were associated with sleep disturbances, psychological distress and impaired health related QoL (HRQoL) [20-25].

Ljosaa et al. [17] showed that physiological factors such as skin pain and disease severity were significantly associated with HRQoL and that the association between skin pain and HRQoL was partly mediated by sleep disturbance, while less by psychological distress.

Other skin symptoms of psoriasis can significantly affect physical functioning, perception of disease, and QoL. These symptoms include itching, “skin shedding”, tightness, redness, dryness, and bleeding [2, 21]. In particular, a direct correlation between pruritus severity and depression has been shown [26]. Psoriatic lesions of the vulva were found in women with psoriasis, resulting in itching, burning and vulvar discomfort, and women with these symptoms more frequently demonstrated depressive symptoms [27].

Psoriatic skin lesions are often perceived by patients as making their physical appearance unsightly; skin lesions make them feeling disfigured and apprehensive that others will avoid or exclude them, resulting in low self-esteem and self-confidence [28, 29].

When psoriasis involves the palms and soles, which occurs in approximately 40% of patients, the pain and discomfort result in significantly greater physical disability than is experienced by patients without palmoplantar involvement [30]. Nail involvement, which is present in up to 50% of patients, may also limit daily activities such as basic self-care activities and housekeeping [31, 32].

3. Psoriatic arthritis

Psoriatic arthritis (PsA) is a painful disease of the joints and connective tissue affecting 10-30% of patients with psoriasis, and is mainly localized at fingers, toes, wrists, hips and back [2, 3, 31, 33]. PsA can result in damage to bone and synovial membranes, pronounced disability, and increased mortality [33]. Patients with PsA have a significantly worse QoL than those without PsA, as measured by different questionnaires [31, 34].

4. Psychological disturbances and psychiatric co-morbidities

Psoriasis is associated with a variety of psychological difficulties, including poor self-esteem, sexual dysfunction, anxiety, depression, and suicidal ideation [35]. The psychiatric morbidity in psoriasis may be primary or secondary to the impact of the disease upon the patients’ QoL.

High depression/anxiety scores, obsessionality and difficulties with verbal expression of emotions, especially anger, social stigmatization, high stress levels, depression, and other psychosocial co-morbidities experienced by patients with psoriasis are not always proportional to, or predicted by, other measurements of disease severity, such as body surface area involvement or plaque severity [36-46]. In general, psychological disturbances, including perception of stigmatization and depression, are stronger determinants of disability in psoriasis patients than are disease severity, location and duration [47]. The Italian PSYCHAE study, which measured psychological distress (PD) in 1580 patients with psoriasis by the General Health Questionnaire-12 (GSQ-12) and the Brief Symptom Inventory (BSI), found that there was no association between disease severity and PD [48].

It is not surprising that perceived stress in patients with psoriasis, as well as with other chronic disease, predicts poorer QoL [49]. On the other hand psoriasis is generally thought to be made worse by stress. Various studies have reported an association between stress and psoriasis. In a study of 132 patients with psoriasis, 39% recalled a significant stressful event within one month before the first episode of psoriasis [50]. In contrast, a more recent prospective clinical study demonstrated that there was no direct relationship between stress and exacerbation of psoriasis, showed no clear relationship between stress levels and worsening of psoriasis and found no time relationships between stress and the appearance of psoriasis [51]. A factor analysis of the Psoriasis Life Stress Inventory revealed two stress-related factors contributing to the psychosocial impact of psoriasis: stress associated with anticipation of the reaction and avoidance by others, and stress associated with patients’ experience or beliefs about being evaluated exclusively on the basis of their skin [52]. So, stress is largely secondary to the cosmetic disfigurement associated with psoriasis, with great impact on QoL and possibly resulting in psychological morbidity.

Studies on the relationship between psychological factors and psoriasis severity have primarily been focused on depression, with conflicting results: some authors have found depression correlated with objective measures of disease severity [49], while others have not [53]. Anyway, relatively high rates of depression are reported in patients with psoriasis [54, 55]. Controlled studies found notably higher degree of depression in patients with psoriasis than in controls [56-58].

Suicidal ideation and cases of completed suicide have been reported in psoriasis. The prevalence of suicidal ideation has been reported to be 2.5% among less severely affected outpatients with <30% of their body surface involved and 7.2% among the more severely affected inpatients as compared to 5.2% in acne patients, 2.1% in atopic dermatitis patients and 0% in alopecia areata patients [57, 59]. Death wishes and suicidal ideation were associated with higher depression scores.

Some reports suggest a higher prevalence of alcohol abuse and cigarette smoking among psoriatic patients [60,61]. In one study, there was an 18% prevalence of alcoholism in patients with psoriasis compared to 2% among dermatologic controls [60]. Several studies have shown that treatment outcomes are worse in heavy drinkers [62-64]. Abstinence alone has been shown to possibly induce psoriasis remission, whereas restarting drinking may cause disease relapse [62, 65].

Concerning the evolution of PD in psoriasis, the longitudinal phase of the PSYCHAE study, that specifically evaluated this aspect in 1500 psoriatic patients during up to 12 months, showed that minor PD halved during the observation period, possibly due to improvement of clinical symptoms, while major PD remained stable [66]. The same authors investigated patients’ coping strategies and found that planning, active coping and acceptance were strategies most commonly employed by their patients while denial, behavioural disengagement, and substance abuse were the least frequent attitudes [48]. During the 12-month follow-up, active coping and avoiding dramatization by recourse to humor were predictive factors of amelioration of PD [66].

5. Stigma

A stigma is severe social disapproval of a person based on a distinguishing characteristics [67]. It has also been defined as a biologic or social mark that sets a person off from others [68]. Visible lesions cause feelings of stigmatization which can lead to psychological stress and social withdrawal [69]. Psoriasis patients, even those with relatively mild symptoms, experience high stigmatization as compared to sufferers of other skin diseases, with significant impact on outcomes such as QoL, depression and disability [70-72]. Stigmatization has many forms: Ginsburg and Link identified different dimensions, including anticipation of rejection, feeling of being flawed, sensitivity to others’ attitude, guilt and shame, reduction of self-esteem [73].

Among the themes at the basis of the stigma experience, shame has an important role. In different studies, patients with psoriasis reported feelings of embarrassment and shame compared to healthy controls [74, 75]. Shame is one of the most reported emotions, especially by women and by patients with a long disease duration [74]. Feelings of shame can have a strong impact on social life, since they can result in avoidance of public spaces, thus reducing social opportunities, even concerning employment [76].

Boehm et al. [67] have found that it is stigmatization that mediates between symptom severity and QoL, in particular the stigmatization parameters ‘reduction of self-esteem’ and ‘rejection’.

6. Gender

Psoriasis does not discriminate by gender. Studies generally show no difference in the severity of physical symptoms suffered by men and women. However, women and men have different subjective perceptions of how symptoms affect their social interactions, emotional states and, ultimately, their QoL.

Men can find it easier to distance themselves from the social effects of psoriasis. Women, in contrast, are more likely to report feeling ‘upset’, ‘disturbed’ or ‘ashamed’ in social settings [77]. Stress research provides another way of understanding differences between men and women’s reactions to psoriasis. Women may be more prone to perceive stress and may be more likely to perceive a greater impact on mental QoL [78].Other authors have shown that women may have a higher likelihood of being stress-reactors [79]. Boehm et al. [67] have found that women reported higher discomfort levels and higher stigmatization, and that, in general, gender differences are observable in the mental component summary score, but not in general-physical or skin-related QoL. The PSYCHAE study, conducted on nearly 1600 Italian psoriasis patients, found that the female gender was the most important predictive factor for psychological distress [48].

7. Sexual health

Psoriasis may involve genital skin. In a Netherlands study, of 1943 patients with psoriasis, over 45% reported genital involvement at some time during the course of the disease [80]. Relatively few studies have evaluated the impact of psoriasis on sexual health, however, according to these studies, psoriasis interferes with sexual relations in 35-50% of patients [76, 81, 82]. Sexual dysfunction and distress are particularly high when genital skin is affected.

Psoriasis has a negative influence on a patient’s desire for physical intimacy [83] and causes decreased libido in a substantial proportion of patients [81]. Feelings of shame and embarrassment about physical appearance and reduced sexual desire might play a major role in high distress and dysfunction scores in specific sexual indexes [84]. Impairment of sexual activity is more profound in patients with more severe psoriatic symptoms [85], and appears to be more prevalent in women [1]. The patients who believe psoriasis has a negative effect on their sexual lives have more symptoms of depression [81].

Also the treatments used by patients with psoriasis may cause sexual dysfunction: some publications report that antipsoriatic medication such as methotrexate and etretinate might cause sexual impotence and erectile dysfunction [86-88].

8. Occupational impact

Psoriasis causes significant occupational disability. Over 17% of patients aged 18-54 report psychologic effects in the workplace due to their disease [2], 6% of employed patients with severe psoriasis reported workplace discrimination [2], and 23% reported that psoriasis affected their choice of career [9]. Problems in work were more frequent in patients with palmoplantar psoriasis. Thus, it appears that psoriasis may have a negative impact on work both for psychological and clinical reasons [2, 9]. Wu et al [89] showed that psoriasis patients were more likely to have missed work for health-related reasons, had significantly more health-related work productivity impairment, and more overall work impairment [90]. This can have financial consequences and may limit lifetime earning potential and career. One study found that 86% of patients with severe psoriasis were ‘moderately’ or ‘a lot’ concerned with the time and costs of treating psoriasis [91]. Moreover, psoriasis prevents some patients from obtaining employment altogether [92]. Two studies in the UK found a lower rate of employment in patients with severe psoriasis [41, 92]. Patients with psoriasis who are working, however, tend to have a low work QoL [91]. Fleischer et al [93] theorized that the effect of psoriasis on a patient’s work life might result in reduced socio-economical standing and limitations and 34% of the study patients reported hardships due to the financial burden of the disease.

9. Impact of QoL on healthcare resources

Poorer QoL of psoriasis patients is associated with increased healthcare resource utilization, independent of the clinical severity of the disease [94]. As stated previously in this chapter, measuring clinical severity of skin lesions does not fully capture the effect of the disease on patient QoL [47, 95].

The study by Sato et al. [94] showed that healthcare resource utilization by European patients with plaque psoriasis, in terms of dermatologist visits and hospitalizations, is greater for those with poorer QoL, independent of clinical disease severity, and may decrease if QoL improves. These authors also found that poor QoL is also associated with employment disadvantages, even when controlling for disease severity, suggesting that indirect costs of psoriasis may also be augmented for patients who have a poor QoL.

10. QoL in children with psoriasis

In childhood, QoL is greatly influenced by psoriasis. Data on QoL in juvenile psoriasis are limited, however some studies demonstrated the negative influence of psoriasis on the QoL of children by means of the Children’s Dermatology Life Quality Index (CDLQI) [96-100].The social development domain, which is one of the developmental milestones in a child, is particularly impaired [101]. Moreover, psoriasis in childhood causes a high degree of limitations on recreational activities in at least 15-30% of patients [101]. Itching and problems with treatments were shown to have the highest impact on the children’s QoL. The same authors showed that QoL in the long term is not determined by the age of onset of psoriasis.

Other authors demonstrated that the significant negative impact of plaque psoriasis on QoL of children with psoriasis is generally comparable to the impact of other serious pediatric chronic diseases, as arthritis, asthma, and diabetes [102]. The impairment in QoL impacts particularly emotional and school functioning [102].

11. Impact of psoriasis treatments on QoL

Only a few clinical trials have been conducted on the effect of treatments for psoriasis on QoL and some of them were not specifically designed to measure QoL but rather inferred the drug impact on QoL from its effect on the clinical symptoms of the disease.

Among topical treatments, calcipotriol-betamethasone gel was reported to improve QoL in patients with scalp psoriasis [103]. Narrowband ultraviolet B (NBUVB) phototherapy administered three times a week for 6 months significantly improved QoL in 95 plaque-type psoriasis patients [104].

Low-dose (3 mg/kg/day), short-term cyclosporine therapy was effective in improving QoL as measured by Skindex-16 and GHQ-28 in 41 patients with mild to severe psoriasis [105]. An Italian longitudinal study on psoriasis patients followed up for 12 months observed that treatment with cyclosporine significantly reduced by 30% the risk for minor psychological distress, while methotrexate and topical corticosteroids were associated with significantly increased risks (33% and 185%, respectively) [66]. Additionally, results from a small study indicate that the use of cyclosporine for the treatment of nail psoriasis can lead to an improvement in QoL [106].

In a Canadian randomized, placebo-controlled trial on 451 plaque psoriasis patients, voclosporin was reported to improve QoL, assessed by DLQI and Psoriasis Disability Index (PDI) [107].

A recent analysis of Japanese trials on infliximab demonstrates that a Psoriasis Area and Severity Index (PASI) 90 response is necessary to achieve a DLQI of 0 or 1. Since infliximab showed to achieve nearly 50% of PASI 90 responses, the authors infer that it might be useful in meeting the goal of a DLQI of 0 or 1 [108].

An analysis of pooled data from two randomized, placebo-controlled trials evaluated the effects of adalimumab on the risk of symptom worsening in psoriasis and the subsequent impact on HRQoL. The analysis pointed out that clinically relevant worsening of psoriasis symptoms was associated with substantial worsening of HRQoL. Adalimumab treatment was associated with a reduction in risk of clinical worsening of psoriasis, but its specific effect on HRQoL was not reported [109].

A metanalysis of randomized, controlled trials of etanercept in patients with rheumatoid arthritis, psoriatic arthritis and psoriasis, evaluating among other outcome measures the effect of the drug on HRQoL, treatment with etanercept resulted in improvements in the physical and mental component summary scores (PCS and MCS), as well as in individual SF-36 domains across all indications [110]. The PRESTA trial, conducted in Germany, evaluated the effect of etanercept on a composite measure of skin symptoms, joint manifestations, and QoL [111]. At 24 weeks, around 30% of patients met the triad of efficacy outcomes. In juvenile plaque psoriasis, one randomized, controlled, longitudinal study described a significant positive effect of etanercept on QoL [100].

In a subanalysis of the PHOENIX 1 and 2 trials on ustekinumab in psoriasis, aimed at evaluating the effect on HRQoL and sexual difficulties, ustekinumab treatment was associated with significant improvement in HRQoL and sexual difficulties due to psoriasis [112]. Another post-hoc analysis of the PHOENIX 2 trial showed that ustekinumab decreases work limitations, improves work productivity and reduces work days missed in the 1230 study patients with moderate-to-severe psoriasis [113]. The efficacy of ustekinumab was also evaluated in nail psoriasis and nail-associated QoL in a population treated for cutaneous psoriasis. Together with a statistically significant reduction of the nail psoriasis severity index (NAPSI), a significant improvement of the international onychomycosis QoL scores was observed at all time points up to 40 weeks [114].

In children, in a psoriatic cohort treated in daily clinical practice, QoL was assessed by CDLQI. The results showed that all psoriasis treatments contributed to a significant improvement in children’s QoL, which was greatest with dithranol and systemic treatments. The highest positive impact with all treatments was observed on itching and sleep disturbances [115].

12. Conclusions and recommendations for clinical practice

Psoriasis is associated with significant psychological distress, psychiatric morbidity, experience of stigmatization and decreased QoL. Several studies have demonstrated the significant negative impact of psoriasis on QoL, which is similar to the impact of other major chronic diseases as heart diseases, diabetes and cancer. Presence of psoriatic arthritis, psychiatric disorders, and other co-morbidities may further worsen QoL and should be taken into account. The association between symptom severity and QoL, though observed by some studies [98,116], is not always strong, and other studies found no significant association at all [48, 95]. Symptom severity has been shown to have a greater direct impact on the physical rather than the mental components of QoL, while the effects of stigmatization on QoL are more strongly mental [67]. Some research has concluded that ‘subjective experience of psoriasis is a more powerful determinant of QoL’ in comparison to clinical measures [117].

Studies have shown that dermatologists employ a problem-orientated coping style in caring’ for their patients, and often appear much more interested in investigating the superficial skin rather than the deep emotions of their patients [48]. On the contrary, it is essential that measures of psychosocial morbidity are included when assessing psoriasis severity.

In clinical practice there is a great challenge for dermatologists to improve the QoL of adults and children with psoriasis. Greater attention should be paid to the possible limitations that these patients experience. The outcome of QoL measurements should be taken into account when deciding on treatment strategies. Dermatology professionals should be encouraged to identify patients, irrespective of gender and of severity of clinical manifestations, who perceive especially high levels of discomfort, indicate problems in maintaining self-esteem and/or have experienced instances of rejection. Specific therapeutic strategies that address issues of self-esteem and social rejection are appropriate especially for these patients. Optimal therapy that leads to long-lasting remission can only be achieved by addressing both the physical and psychosocial effects of psoriasis. The choice of the optimal psoriasis treatment should also take into account the effect of the drug on the patient’s psychosocial well-being, and adjunctive psychological interventions before and during treatment may be of benefit for selected patients. It is recommended that psoriasis patients, especially those with severe disease, receive a more holistic, multitarget approach that encompasses both medical and psychological measures.


1 - De Arruda LH, De Moares AP. The impact of psoriasis on quality of life. Br J Dermatol 2001; 144:33–6
2 - 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; 137:280–4
3 - Zachariae R, Zachariae H, Blomqvist K et al. Quality of life in 6497 Nordic patients with psoriasis. Br J Dermatol 2002; 146:1006–16
4 - Mease PJ, Menter MA. Quality-of-life issues in psoriasis and psoriatic arthritis: outcome measures and therapies from a dermatological perspective. J Am Acad Dermatol 2006; 54: 685–704.
5 - Mukhtar R, Choi J, Koo JY. Quality-of-life issues in psoriasis. Dermatol Clin 2004; 22: 389–395.
6 - Tadros A, Vergou T, Stratigos A et al. Psoriasis: is it the tip of the iceberg for the quality of life of patients and their families? Eur Acad Dermatol Venereol 2011; 25:1282–7
7 - 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 Acad Dermatol 2004; 51:704–8
8 - Fortune DG, Richards HL, Griffiths CE. Psychologic factors in psoriasis: consequences, mechanisms, and interventions. Dermatol Clin 2005; 23:681–94
9 - Weiss SC, Kimball AB, Liewehr DJ et al. Quantifying the harmful effect of psoriasis on health-related quality of life. J Am Acad Dermatol 2002; 47:512–8
10 - Feldman SR, Koo JY, Menter A et al. Decision points for the initiation of systemic treatment for psoriasis. J Am Acad Dermatol 2005; 53:101–7
11 - Rapp SR, Feldman SR, Exum ML et al. Psoriasis causes as much disability as other major medical diseases. J Am Acad Dermatol 1999; 41:401–7
12 - Kimball AB, Guerin A, Mulani P et al. The risk of coronary heart disease and stroke among psoriasis patients. Abstract P 3369 AAD. J Am Acad Dermatol 2009; 60: Suppl AB179.
13 - Ludwig RJ, Herzog C, Rostock A et al. Psoriasis: a possible risk factor for development of coronary artery calcification. Br J Dermatol 2007; 156: 271–276.
14 - Neimann AL, Shin DB, Wang X, Margolis DJ, Troxel AB, Gelfand JM. Prevalence of cardiovascular risk factors in patients with psoriasis. J Am Acad Dermatol 2006; 55: 829–835.
15 - Patrick DL, Deyo RA. Generic and disease-specific measures in assessing health status and quality of life. Med Care 1989; 27[3 Suppl):S217–32
16 - Ljosaa TM, Rustoen T, Mork C et al. Skin pain and discomfort in psoriasis: an exploratory study of symptom prevalence and characteristics. Acta Derm Venereol 2010; 90: 39–45.
17 - Ljosaa TM, Mork C, Stubhaug A, Mourn T, Wahl AK. Skin pain and skin discomfort is associated with quality of life in patients with psoriasis. J Eur Acad Dermatol Venereol 2012; 26:29-35
18 - Sampogna F, Gisondi P, Melchi CF, Amerio P, Girolomoni G, Abeni D. Prevalence of symptoms experienced by patients with different clinical types of psoriasis. Br J Dermatol 2004; 151: 594–599.
19 - McKenna KE, Stern RS. The impact of psoriasis on the quality of life of patients from the 16-center PUVA follow-up cohort. J Am Acad Dermatol 1997; 36: 388–394.
20 - Fortune DG, Richards HL, Griffiths CE. Psychologic factors in psoriasis: consequences, mechanisms, and interventions. Dermatol Clin 2005; 23: 681–694.
21 - Yosipovitch G, Goon A, Wee J, Chan YH, Goh CL. The prevalence and clinical characteristics of pruritus among patients with extensive psoriasis. Br J Dermatol 2000; 143: 969–973.
22 - Globe D, Bayliss MS, Harrison DJ. The impact of itch symptoms in psoriasis: results from physician interviews and patient focus groups. Health Qual Life Outcomes 2009; 7: 62.
23 - Choi J, Koo JY. Quality of life issues in psoriasis. J Am Acad Dermatol 2003; 49: 57–61.
24 - Zachariae R, Zachariae C, Ibsen HH, Mortensen JT, Wulf HC. Psychological symptoms and quality of life of dermatology outpatients and hospitalized dermatology patients. Acta Derm Venereol 2004; 84: 205–212.
25 - Wahl A, Moum T, Hanestad BR, Wiklund I. The relationship between demographic and clinical variables, and quality of life aspects in patients with psoriasis. Qual Life Res 1999; 8: 319–326.
26 - Gupta MA, Gupta AK, Schork NJ, Ellis CN. Depression modulates pruritus perception: a study of pruritus in psoriasis, atopic dermatitis, and chronic idiopathic urticaria. Psychosom Med 1994; 56: 36–40.
27 - Zamirska A, Reich A, Berny-Moreno J, et al. Vulvar pruritus and burning sensation in women with psoriasis. Acta Derm Venereol 2008; 88: 132–135.
28 - McHenry PM, Doherty VR. Psoriasis: an audit of patients’ views on the disease and its treatment. Br J Dermatol 1992; 127: 13–17.
29 - Koo J. Population-based epidemiologic study of psoriasis with emphasis on quality of life assessment. Dermatol Clin 1996; 14: 485–496.
30 - Pettey AA, Balkrishnan R, Rapp SR, et al. Patients with palmoplantar psoriasis have more physical disability and discomfort than patients with other forms of psoriasis: implications for clinical practice. J Am Acad Dermatol 2003; 49: 271–275.
31 - National Psoriasis Foundation Data. 2004; [online]. Available at:
32 - de Jong EM, Seegers BA, Gulinck MK, et al. Psoriasis of the nails associated with disability in a large number of patients: results of a recent interview with 1728 patients. Dermatology 1996; 193: 300–303.
33 - Gladman DD, Rahman P. Psoriatic arthritis. In: Ruddy S, Harris ED, Sledge CB, et al., eds. Kelley’s Textbook of Rheumatology, 6th edn. Philadelphia, PA: WB Saunders Company, 2001: 1071–1078.
34 - Rosen CF, Mussani F, Chandran V, Eder L, Thavaneswaran A, Gladman DD. Patients with psoriatic arthritis have worse quality of life than those with psoriasis alone. Rheumatology (Oxford) 2012; 51:571-6
35 - Basavaraj , Navya MA, Rashmi R. Stress and quality of life in psoriasis: an update. Int J Dermatol 2011; 50:783-92.
36 - Gupta MA, Gupta AK, Watteel GN. Early onset (<age 40 years) psoriasis is associated with greater psychopathology than late onset psoriasis. Acta Derm Venereol 1996; 76: 464–466.
37 - Niemeier V, Nippesen M, Kupfer J, et al. Psychological factors associated with hand dermatoses: which subgroup needs additional psychological care? Br J Dermatol 2002; 146: 1031–1037.
38 - Skevington SM, Bradshaw J, Hepplewhite A, et al. How does psoriasis affect quality of life? Assessing an Ingram-regimen outpatient programme and validating the WHOQOL-100. Br J Dermatol 2006; 154: 680–691.
39 - Feldman SR, Fleischer AB Jr, Reboussin DM, et al. The economic impact of psoriasis increases with psoriasis severity. J Am Acad Dermatol 1997; 37: 564–569.
40 - Kirkby B, Richards HL, Woo P, et al. Physical and psychological measures are necessary to assess overall psoriasis severity. J Am Acad Dermatol 2001; 45:72–76.
41 - Fortune DG, Main CJ, O’Sullivan TM, Griffiths CE. Quality of life in patients with psoriasis: the contribution of clinical variables and psoriasis-specific stress. Br J Dermatol 1997; 137: 755–760.
42 - Gupta MA, Gupta AK, Haberman HF. Psoriasis and psychiatry: an update. Gen Hosp Psychiatry 1987; 9:157–166.
43 - Matussek P, Agerer D, Seibt G. Aggression in depressives and psoriatics. Psychother Psychosom 1985;43: 120–125.
44 - Rubino IA, Sonnino A, Pezzarossa B, et al. Personality disorders and psychiatric symptoms in psoriasis. Psychol Rep 1995; 77: 547–553.
45 - Vidoni D, Campiutti E, D’Aronco R, et al. Psoriasis and alexithymia. Acta Derm Venereol (Stockh) 1989; 146:91–92.
46 - Kimball AB, Jacobson C, Weiss S, et al. The psychosocial burden of psoriasis. Am J Clin Dermatol 2005; 6: 383–392.
47 - Richards HL, Fortune DG, Griffiths CE, Main CJ. The contribution of perceptions of stigmatisation to disability in patients with psoriasis. J Psychosom Res 2001; 50:11–15.
48 - Finzi A, Colombo D, Caputo A, Andreassi L, Chimenti S, Vena G, Simoni L, Sgarbi S, Giannetti A for the PSYCHAE Study Group.Psychological distress and coping strategies in patients with psoriasis: the PSYCHAE Study. J Eur Acad Dermatol Venereol 2007; 21:1161-9
49 - O’Leary CJ, Creamer D, Higgins E, Weinman J. Perceived stress, stress attributions and psychological distress in psoriasis. J Psychosom Res 2004; 57: 465–471.
50 - Polenghi MM, Molinari E, Gala C, et al. Experience with psoriasis in a psychosomatic dermatology clinic.Acta Derm Venereol (Stockh) 1994; 186: 65–66.
51 - Berg M, Svensson M, Brandberg M, Nordlind K. Psoriasis and stress: a prospective study. J Eur Acad Dermatol Venereol 2008; 22: 670–674.
52 - Fortune DG, Main CJ, O’Sullivan TM, Griffiths CE. Assessing illness-related stress in psoriasis: the psychometric properties of the Psoriasis Life Stress Inventory. J Psychosom Res 1997; 42: 467–475.
53 - Schmitt JM, Ford DE. Role of depression in quality of life for patients with psoriasis. Dermatology 2007; 215:17-27
54 - Bouguéon K, Misery L. Depression and psoriasis. Ann Dermatol Venereol 2008; 135: 254–258.
55 - Van Voorhees AS, Fried R. Depression and quality of life in psoriasis. Postgrad Med 2009; 121: 154–161
56 - Hardy GE, Cotterill JA. A study of depression and obsessionality in dysmorphophobic and psoriasis patients. Br J Psychiatry 1982; 140: 19–22.
57 - Gupta MA, Gupta AK. Depression and suicidal ideation in dermatology patients with acne, alopecia areata, atopic dermatitis and psoriasis. Br J Dermatol 1998; 139: 846–850.
58 - Devrimci-Ozguven H, Kundakci TN, Kumbasar H, Boyvat A. The depression, anxiety, life satisfaction and affective expression levels in psoriasis patients. J Eur Acad Dermatol Venereol 2000; 14: 267–271.
59 - Gupta MA, Schork NJ, Gupta AK, et al. Suicidal ideation in psoriasis. Int J Dermatol 1993; 32: 188–190.
60 - Morse RM, Perry HO, Hurt RD. Alcoholism and psoriasis. Alcohol Clin Exp Res 1985; 9: 396–399.
61 - Mills CM, Srivastava RD, Harvey IM, et al. Smoking habits in psoriasis: a case control study. Br J Dermatol 1992; 127: 18–21.
62 - Higgins EM, du Vivier AW. Alcohol abuse and treatment resistance in skin disease [letter]. J Am Acad Dermatol 1994; 30: 1048.
63 - Higgins EM, du Vivier AW. Cutaneous disease and alcohol misuse. Br Med Bull 1994; 50: 85–98.
64 - Gupta MA, Schork NJ, Gupta AK, Ellis CN. Alcohol intake and treatment responsiveness of psoriasis: a prospective study. J Am Acad Dermatol 1993; 28:730–732.
65 - Vincenti GE, Blunden SM. Psoriasis and alcohol abuse. J R Army Med Corps 1987; 133: 77–78.
66 - Colombo D, Caputo A, Finzi A et al for the PSYCHAE Study Group. Evolution of and risk factors for psychological distress in patients with psoriasis: the PSYCHAE study. Int J Immunopathol Pharmacol 2010; 23:297-306
67 - Boehm D, Stock Gissendanner S, Bangemann K et al. Perceived relationships between severity of psoriasis symptoms, gender, stigmatization and quality of life. J Eur Acad Dermatol Venereol 2012; DOI: 10.1111/j.1468-3083.2012.04451.x
68 - Jones E, Farina A, Hastorf A, Markus H, Miller D. Social stigma: the psychology of marked relationships. New York: Freeman, 1984
69 - Hrehorow E, Salomon J, Matusiak L et al. Patients with psoriasis feel stigmatized. Acta Derm Venereol 2011; 92: 67–72.
70 - Gupta MA, Gupta AK, Watteel GN. Perceived deprivation of social touch in psoriasis is associated with greater psychologic morbidity: an index of the stigma experience in dermatologic disorders. Cutis 1998; 61:339–342.
71 - Richards HL, Fortune DG, Griffiths CE, Main CJ. The contribution of perceptions of stigmatisation to disability in patients with psoriasis 26. J Psychosom Res 2001; 50:11–15.
72 - Schmid-Ott G, Jaeger B, Kuensebeck HW et al. Dimensions of stigmatization in patients with psoriasis in a ‘Questionnaire on Experience with Skin Complaints’ 31. Dermatology 1996; 193: 304–310.
73 - Ginsburg IH, Link BG. Feelings of stigmatization in patients with psoriasis. J Am Acad Dermatol 1989; 20: 53–63.
74 - Sampogna F, Tabolli S, Abeni D, and the IDI Multipurpose Psoriasis Research on Vital Experiences (IMPROVE) Investigators. Living with psoriasis: prevalence of shame, anger, worry, and problems in daily activities and social life. Acta Derm Venereol 2012; 92:299-303
75 - Magin P, Adams J, Heading G, Pond D, Smith W. The psychological sequelae of psoriasis: results of a qualitative study. Psychol Health Med 2009; 14:150-61
76 - Weiss SC, Kimball AB, Liewehr DJ, Blauwelt A, Turner ML, Emanuel EJ. Quantifying the harmful effect of psoriasis on health-related quality of life. J Am Acad Dermatol 2002; 47:512-8
77 - Perrott SB, Murray AH, Lowe J, Ruggiero KM. The personal-group discrimination discrepancy in persons living with psoriasis. Basic Appl Social Psychol 2000; 22: 57–67.
78 - 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.
79 - 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.
80 - Meeuwis KA, de Hullu JA, de Jager ME et al. Genital psoriasis: a questionnaire-based survey on a concealed skin disease in the Netherlands. J Eur Acad Dermatol Venereol 2010; 24:1425–30.
81 - Gupta MA, Gupta AK. Psoriasis and sex: a study of moderately to severely affected patients. Int J Dermatol 1997; 36: 259–262.
82 - Ramsay B, O’Reagan M. A survey of the social and psychological effects of psoriasis. Br J Dermatol 1988; 118: 195–201.
83 - Wahl AK, Gjengedal E, Hanestad BR. The bodily suffering of living with severe psoriasis: in-depth interviews with 22 hospitalized patients with psoriasis. Qual Health Res 2002; 12: 250–261.
84 - Meeuwis KA, de Hullu JA, van de Nieuwenhof HP, Evers AW, Massuger LF, van de Kerkhof PC, van Rossum MM. Quality of life and sexual health in patients with genital psoriasis. Br J Dermatol 2011; 164: 1247-55
85 - Koo J. Population-based epidemiologic study of psoriasis with emphasis on quality of life assessment. Dermatol Clin 1996; 14:483-96
86 - Aguirre MA, Velez A, Romero M et al. Gynecomastia and sexual impotence associated with methotrexate treatment. J Rheumatol 2002; 29:1793–4.
87 - Reynolds OD. Erectile dysfunction in etretinate treatment. Arch Dermatol 1991; 127:425–6.
88 - Wylie G, Evans CD, Gupta G. Reduced libido and erectile dysfunction: rarely reported side-effects of methotrexate. Clin Exp Dermatol 2009; 34:e234.
89 - Wu Y, Mills D, Bala M. Impact of psoriasis on patients’ work and productivity: a retrospective, matched case-control analysis. Am J Clin Dermatol 2009; 10:407-10
90 - Horn EJ, Fox KM, Patel V, chiou CF, Dann F, Lebwohl M. Association of patient-reported psoriasis severity with income and employment. J Am Acad Dermatol 2007; 57:963-71
91 - Feldman SR, Fleischer AB Jr, Reboussin DM, et al. The economic impact of psoriasis increases with psoriasis severity. J Am Acad Dermatol 1997; 37:564–569.
92 - Finlay AY, Coles EC. The effect of severe psoriasis on the quality of life of 369 patients. Br J Dermatol 1995; 132: 236–244.
93 - Fleischer AB Jr, Feldman SR, Bradham DD. Office-based physician services provided by dermatologists in the United States in 1990. J Invest Dermatol 1994; 102:93–97.
94 - Sato R, Milligan G, Molta C, Singh A. Health-related quality of life and healthcare resource use in European patients with plaque psoriasis: an association independent of observed disease severity. Clin Exper Dermatol 2010; 36:24-28
95 - Perrott SB, Murray AH, Lowe J, Mathieson CM. The psychosocial impact of psoriasis: physical severity, quality of life, and stigmatization. Physiol Behav 2000; 70: 567–71.
96 - Lewis-Jones MS, Finlay AY. The Children’s Dermatology Life Quality Index (CDLQI): initial validation and practical use. Br J Dermatol 1995; 132:942–9.
97 - Beattie PE, Lewis-Jones MS. A comparative study of impairment of quality of life in children with skin disease and children with other chronic childhood diseases. Br J Dermatol 2006; 155:145–51.
98 - de Jager ME, van de Kerkhof PC, de Jong EM et al. A cross-sectional study using the Children’s Dermatology Life Quality Index (CDLQI) in childhood psoriasis: negative effect on quality of life and moderate correlation of CDLQI with severity scores. Br J Dermatol 2010; 163:1099–101.
99 - Ganemo A, Wahlgren CF, Svensson A. Quality of life and clinical features in Swedish children with psoriasis. Pediatr Dermatol 2011; 28:375–9.
100 - Langley RG, Paller AS, Hebert AA et al. Patient-reported outcomes in pediatric patients with psoriasis undergoing etanercept treatment: 12-week results from a phase III randomized controlled trial. J Am Acad Dermatol 2011; 64:64–70.
101 - De Jager ME, de Jong EM, van de Kerkhof PC, Evers AE, Seyger MM. An intrapatient comparison of quality of life in psoriasis in childhood and adulthood. J Eur Acad Dermatol Venereol 2011; 25:828-31
102 - Varni JW, Globe DR, Gandra SR, Harrison DJ, Hooper M, Baumgartner S. Health-related quality of life of pediatric patients with moderate to severe plaque psoriasis: comparisons to four common chronic diseases. Eur J Pediatr 2012; 171:485-92
103 - Mrowietz U, Macheleidt O, Eicke C. Effective treatment and improvement of quality of life in patients with scalp psoriasis by topical use of calcipotriol/betamethasone (Xamiol®-gel): results. J Dtsch Dermatol Ges 2011; 9:825-31
104 - Al Robaee AA, Alzolibani AA. Narrowband ultraviolet B phototherapy improves the quality of life in patients with psoriasis. Saudi Med J 2011; 32:603-6
105 - Okubo Y, Natsume S, Usui K, Amaya M, Tsuboi R. Low-dose, short-term ciclosporin (Neoral®) therapy is effective in improving patients’ quality of life as assessed by Skindex-16 and GHQ-28 in mild to severe psoriasis patients. J Dermatol 2011;38:465-72
106 - Abe M, Syuto T, Yokoyama Y, Ishikawa O. Improvement of quality of life and clinical usefulness of cyclosporin administration in patients with nail psoriasis. J Dermatol 2011; 38:916-49
107 - Kunynetz R, Carey W, Thomas R, Toth D, Trafford T, vender R. Quality of life in plaque psoriasis patients treated with voclosporin: a Canadian phase III, randomized, multicenter, double-blind, placebo-controlled study. Eur J Dermatol 2011; 21:89-94
108 - Torii H, Sato N, Yoshinari T, Nakagawa H. Dramatic impact of a Psoriasis Area and Severity Index 90 response on the quality of life in patients with psoriasis: an analysis of Japanese clinical trials of infliximab. J Dermatol 2012; 39:253-9
109 - Papp KA, Signorovitch J, Ramakrishnan K, Yu AP, Gupta SR, Bao Y, Mulani PM. Effects of adalimumab versus placebo on risk of symptom worsening in psoriasis and subsequent impacts on health-related quality of life: analysis of pooled data from two randomized, double-blind, placebo –controlled, multicentre clinical trials. Clin Drug Investig 2011; 31:51-60
110 - Strand V, Sharp V, Koenig AS, Park G, Shi Y, Wang B, Zack DJ, Fiorentino D. Comparison of health-related quality of life in rheumatoid arthritis, psoriatic arthritis an psoriasis and effects of etanercept treatment. Ann Rheum Dis 2012; 71:1143-50
111 - Prinz JC, Fitzgerald O, Boggs RI, Foehl J, Robertson D, Pedersen R, Molta CT, Freundlich B. Combination of skin, joint and quality of life outcomes with etanercept in psoriasis and psoriatic arthritis in the PRESTA trial. J Eur Acad Dermatol Venereol 2011; 25:559-64
112 - Guenther L, Han C, Szapary P, Schenkel B, Poulin Y, Bourcier M, Ortonne JP, Sofen HL. Impact of ustekinumab on health-related quality of life and sexual difficulties associated with psoriasis: results from two phase III clinical trials. J Eur Acad Dermatol Venereol 2011; 25:851-7
113 - Reich K, Schenkel B, Zhao N, Szapary P, Augustin M, Bourcier M, Guenther L, Langley RG. Ustekinumab decreases work limitations, improves work productivity, and reduces work days missed in patients with moderate-to-severe psoriasis: results from PHOENIX 2. J Dermatolog Treat 2011; 22:337-47
114 - Rigopoulos D, Gregoriou S, Makris M, Ioannides D. Efficacy of ustekinumab in nail psoriasis and improvement in nail-associated quality of life in a population treated with ustekinumab for cutaneous psoriasis: an open prospective unblended study. Dermatology 2011; 223:325-9
115 - Oostven AM, de Jager ME, ven de Kerkhof PC, Donders AR; de Jong EM, Seyger MM. The influence of treatments in daily clinical practice on the Children’s Dermatology Life Quality Index in juvenile psoriasis: a longitudinal study from the Child-CAPTURE patient registry. Br J Dermatol 2012; 167:145-9
116 - Augustin M, Kruger K, Radtke MA et al. Disease severity, quality of life and health care in plaque-type psoriasis: a multicenter cross-sectional study in Germany. Dermatology 2008; 216: 366–372.
117 - Russo PA, Ilchef R, Cooper AJ. Psychiatric morbidity in psoriasis: a review. Australas J Dermatol 2004; 45: 155–159