PracticalDermatology

Imagine that you are a 13-year-old girl and it’s a beautiful summer day. On entering a community swimming pool, you’re asked what’s on your elbows. You are then told that you cannot enter without a note from your doctor. Think about how that not only ruined your perfect vacation day—looking forward to playing with your friends—but the impact it had on your self esteem, the self doubts you have about yourself, and the way you behave with others. In reality, psoriasis directly impacts patients’ psychological states. We clinicians must be aware of these facts and weigh them when selecting treatments.

The Psychological Impact of Psoriasis

Living with psoriasis is a major emotional burden that compares to the stress of having congestive heart failure and chronic obstructive pulmonary disorder.¹ Psoriasis affects sleeping and sexual activities in over half of all nights in 12 percent of patients, and at least one night a month in 35 percent of patients. Psoriatic patients on average get 20 minutes less sleep per night than non-psoriatics.²

Psoriasis has been tied to several psychological conditions and disorders. Patients with severe psoriasis have a 72 percent increased frequency of depression than non-psoriatic patients.3 Patients with mild psoriasis are at a 38 percent increased risk for depression compared to non-psoriatic patients.³ Thus, it should be no surprise to dermatologists that psoriatic patients use selective serotonin reuptake inhibitors at a rate 71 percent higher than non-psoriatic patients.⁴

Psychological disorders affect the pediatric psoriasis population, as well. A study revealed that 5.3 percent of psoriatic pediatric patients were diagnosed with a psychiatric disorder, as compared to four percent of psoriasis-free controls.⁵ Psychiatric disorders with the highest incidence among psoriasis patients were depression and anxiety. In addition, 8.2 percent of psoriatic children used some drug for a psychiatric disorder, as compared to five percent of those without psoriasis.

Given the measurable psychological impact of psoriasis, delivering adequate treatment is imperative. Several compelling studies have articulated the extent to which aggressive intervention for psoriatic disease can also relieve psychological burdens. A 2012 study found that patients treated with adalimumab (Humira, AbbVie) significantly improved sleep quality by 15 percent from baseline, as well as DLQI score, pain and work productivity, and PASI score.⁶ Use of biologic therapies has also been associated with a decrease in depression and anxiety. In one study, patients treated with etanercept (Enbrel, Amgen) showed a significant improvement in depression within four weeks, compared to placebo. Effective treatment of psoriasis may also relieve symptoms of anxiety.⁷ Results from another study found that patients treated with ustekinumab (Stelara, Janssen) over a 12-week period exhibited a 35 percent decrease in anxiety, in addition to a 50 percent decrease in depression.⁸

Steps for Healthy Patient Interaction

These data underscore the importance of maintaining strong relationships with our patients. Good communication is essential to determine the toll that psoriasis takes on a patient’s life. This not only aids in treatment selection, but it makes the patient feel understood and accepted. Building a trusting relationship with the patient starts with the very first meeting: Present yourself as someone who will convey total attention and listen to your patients’ concerns and frustrations. When introducing yourself, I recommend shaking the patient’s hand and maintaining consistent eye contact, as this helps put the patient at ease and establishes a safe, open environment to disclose her or his feelings. Then ask, “How can I help you?” This conveys not just your willingness to treat the patient’s disease, but also your desire to help the patient by any means necessary. In response, the patient usually shares her or his experience with psoriasis to varying degrees. Some patients are direct in their wish for successful treatment, while others seem more affected by the psychosocial effects of the disease. How each patient responds can help you understand how that patient is affected by her or his experience with the disease and can help you to decide on the degree to which you treat the patient.

I ask patients if they wear long sleeves to hide their psoriasis. You might also consider asking women if they avoid dark clothing so flaking does not show on their clothes. I often ask how much the patient is itching, to get a sense of the pain the plaques cause. All of these questions help patients relate to your understanding of their issues with psoriasis. It also demonstrates empathy, enhancing the patientphysician dynamic.

Once you are ready to examine the patient’s skin, I recommend placing your hand on their psoriasis; this reminds the patient that the disease is not contagious. In addition, most patients are accustomed to people not wanting to look at or touch their psoriasis; a “hands-on” approach communicates a level of trust that patients often welcome. This lets patients know that you will take their problems seriously while ensuring an objective evaluation of their psoriasis. These simple steps may increase patients’ compliance and willingness to try different therapies and help build the long-term relationships necessary for effective psoriasis management.

Caring for Well Being

With the convincing links drawn between psoriatic disease and psychological conditions, we can conclude that psoriasis is more than just a skin disease and affects the overall health of our patients. This likely explains why psoriasis has been shown to affect major life choices, such as where one goes to college, friends and professions, partner selection, and so on. When clinicians treat psoriasis, we also treat patients’ psychological well-being. If we can improve a patient’s psoriasis, we can also immeasurably improve his/her confidence and general disposition. This means selecting appropriate therapies while maintaining a strong relationship with patients based on trust.

Dr. Bagel has served as consultant, researcher, or speaker for Amgen, LEO, Abbott, Janssen, Galderma, and GlaxoSmithKline.

Jerry Bagel, MD, FAAD, is director of the Psoriasis Treatment Center of Central New Jersey.

1. Rapp, SR, et al. Psoriasis causes as much disability as other major medical diseases. JAAD. 1999. 41: 401.
2. Duffin, CK. Psoriatic arthritis is a strong predictor of sleep interference in patients with psoriasis. JAAD. 2009. 60(4): 604-608.
3. Kimball, AB. Economic burden of comorbidities in patients with psoriasis is substantial. JEADV. 2011. 25: 157.
4. Dabbous, D. AAD 2006. Poster 2743.
5. \Kimball AB, et al. Risks of developing psychiatric disorders in pediatric patients with psoriasis. JAAD. October 2012; 67(4): 651-7.e1-2.
6. Strober BE et al. Sleep quality and other patient-reported outcomes improve after patients with psoriasis with suboptimal response to other systemic therapies are switched to adalimumab. BJD. 2012. 2012 Dec; 167(6): 1374-8.
7. Tyring, S. et al. Etanercept and clinical outcomes, fatigue, and depression in psoriasis: double-blind placebo-controlled randomised phase III trial. The Lancet. 2006. 367: 29.
8. Langley, RG. Ustekinumab significantly improves symptoms of anxiety, depression, and skin-related quality of life in patients with moderate-tosevere psoriasis. JAAD. 2010:63(3) 457-465.