Psycho Psoriasis

Acta Derm Venereol. 2009;89(4):364-8. doi: 10.2340/00015555-0669.
Relevance of psychosomatic factors in psoriasis: a case-control study.

Jankovi S, Raznatovi M, Marinkovi J, Maksimovi N, Jankovi J, Djikanovi B.
Source
Institute of Epidemiology, School of Medicine, University of Belgrade, Visegradska 26 11000 Belgrade, Serbia. slavenka@eunet.rs
Abstract
The aim of this study was to assess the role of stressful life events, lack of social support and attachment insecurity in triggering exacerbations of psoriasis. Outpatients experiencing exacerbation of psoriasis in the last 6 months (n = 110) were compared with outpatients affected by skin conditions in which psychosomatic factors are believed to play a minor role (n = 200). Stressful life events during the last 12 months were assessed with Paykel's Interview for Recent Life Events. Perceived social support and attachment relationship were assessed with the Multidimensional Scale of Perceived Social Support and Experiences in Close Relationships Scale, respectively. In comparison with controls the patients with psoriasis reported more stressful life events in the last year. The statistically significant difference was found only for the sum of the first 25 events (odds ratio (OR) 1.98; 95% confidence interval (CI) 1.37-2.87; p < 0.001). Also, patients with psoriasis were more likely to score higher on both anxiety (OR = 1.44; CI = 1.09-1.92; p = 0.011) and avoidance attachment scale (OR = 1.49; CI = 1.04-2.14; p = 0.030), and perceived less support from their social network than did the comparison subjects. The results of this study confirm the relevance of psychosocial factors in psoriasis. PMID: 19688147 [PubMed - indexed for MEDLINE] Psychosomatics. 2005 Nov-Dec;46(6):556-64.
Stress, social support, emotional regulation, and exacerbation of diffuse plaque psoriasis.
Picardi A, Mazzotti E, Gaetano P, Cattaruzza MS, Baliva G, Melchi CF, Biondi M, Pasquini P.
Source
Clinical Epidemiology Unit, Dermatological Institute IDI-IRCCS, and the Department of Psychiatric Sciences and Psychological Medicine, La Sapienza University, Rome, Italy. a.picardi@idi.it
Abstract
The authors' aim was to investigate the role of stressful events, perceived social support, attachment security, and alexithymia in triggering exacerbations of diffuse plaque psoriasis. Inpatients experiencing a recent exacerbation of diffuse plaque psoriasis (N=33) were compared with inpatients with skin conditions believed to have a negligible psychosomatic component (N=73). Stressful events during the last year were assessed with Paykel's Interview for Recent Life Events. Attachment style, alexithymia, and perceived social support were assessed with the Experiences in Close Relationships questionnaire, the Toronto Alexithymia Scale, and the Multidimensional Scale of Perceived Social Support, respectively. Multiple logistic regression analysis was used to control for age, gender, education, marital status, and alcohol consumption. In relation to comparison subjects, the patients with psoriasis had lower perceived social support and higher attachment-related avoidance. Also, they were more likely to have high alexithymic characteristics. There were no differences between the patients with psoriasis and the comparison subjects in scores on the Experiences in Close Relationships anxiety scale, the total number of stressful events, and the number of undesirable, uncontrollable, or major events. Although caution should be applied in generalizing these findings to outpatients, this study suggests that alexithymia, attachment-related avoidance, and poor social support might increase susceptibility to exacerbations of diffuse plaque psoriasis, possibly through impaired emotional regulation. Several physiological mechanisms involving the neuroendocrine and the immune system might mediate the interplay between stress, personality, and diffuse plaque psoriasis. PMID: 16288135 [PubMed - indexed for MEDLINE]
J Psychosom Res. 2003 Sep;55(3):189-96.
Only limited support for a role of psychosomatic factors in psoriasis. Results from a case-control study.
Picardi A, Pasquini P, Cattaruzza MS, Gaetano P, Baliva G, Melchi CF, Tiago A, Camaioni D, Abeni D, Biondi M.
Source
Clinical Epidemiology Unit, Dermatological Institute IDI-IRCCS, Via dei Monti di Creta, 10400167, Rome, Italy. a.picardi@idi.it
Abstract
OBJECTIVE:
To investigate the role of stressful events, social support, attachment security and alexithymia in triggering or exacerbating psoriasis.
METHODS:
Outpatients experiencing a recent onset or exacerbation of psoriasis (n=40) were compared with outpatients with skin conditions in which psychosomatic factors are regarded as negligible (n=116). Stressful events during the last year were assessed with Paykel's Interview for Recent Life Events. Attachment style, alexithymia and perceived social support were assessed with the ECR questionnaire, the TAS-20 and the MSPSS, respectively.
RESULTS:
The mean number of recently experienced life events, or of undesirable, uncontrollable or major events was not different between psoriatic patients and controls. The only stress measure that showed a slight trend towards an association with psoriasis was having experienced four or more stressful events in the preceding year. There was a statistical trend towards an association between alexithymia and psoriasis, whereas there were no significant differences between patients with psoriasis and controls with respect to perceived social support and attachment security. Subgroup analysis suggested that the role of all psychosomatic factors studied might be more important in certain clinical types, such as guttate and diffuse plaque psoriasis.
CONCLUSIONS:
Our findings provide only limited support for a role of psychosomatic factors in psoriasis. Future studies should investigate chronic and daily stressors in addition to major life events, include measures of stress appraisal and include specifically patients with a recent onset of disease.
PMID: 12932790 [PubMed - indexed for MEDLINE]
Arch Dermatol Res. 2012 August; 304(6): 421432. Published online 2012 March 29. doi: 10.1007/s00403-012-1235-3
PMCID: PMC3401292
Social support and adaptation to the disease in men and women with psoriasis
Konrad Janowski, 1 Stanisawa Steuden,2 Aldona Pietrzak,3 Dorota Krasowska,3 ukasz Kaczmarek,2 Ilona Gradus,2 and Grayna Chodorowska3 Author information Article notes Copyright and License information This article has been cited by other articles in PMC. Go to:
Abstract
Social support was shown to be an important factor buffering negative effects of stress in a range of clinical populations. Little is known, however, about the role of social support in the population of patients with psoriasis although strong psychosocial stress has been implicated in this disease. The objective of this study was to evaluate the association between social support and selected indices of adaptation to life with the disease, including health-related quality of life, depressive symptoms and acceptance of life with the disease, in a sample of patients with psoriasis. Additionally, gender differences in these relationships were analyzed. One-hundredfour patients with psoriasis completed psychological tests measuring disease-related social support, health-related quality of life, depressive symptoms and acceptance of life with the disease. Psoriasis severity was assessed by Psoriasis Area and Severity Index. The patients reporting higher social support levels had significantly higher quality of life, lower depression levels, and higher acceptance of life with the disease. The strengths of these effects, however, were different in women and men. Higher social support was slightly more closely associated with better acceptance of life with the disease in men than in women. However, higher social support was more closely associated to lower depression and better quality of life in women than in men. Among different types of social support, tangible support was found to be the best predictor for the all adaptation indices. Effects of social support perceived by psoriasis patients on adaptation to the disease may be gender-related and exact pathways of these effects may depend on the type on the dimension of social support and the selected type of adaptation indicator. Tangible support seems the most important type of support contributing to better adaptation in both women and men with psoriasis.
Keywords: Social support, Quality of life, Psoriasis, Adaptation to disease, Depressive symptoms, Gender differences Go to:
Introduction
Adaptation to living with a disease is a broad term which encompasses a range of phenomena, including quality of life, emotional well being, good self-esteem, acceptance of life with a disease, social participation and fulfilment of social roles [ The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version.
Destroy user interface control9,
The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version.
Destroy user interface control45]. In chronic diseases, such as psoriasis, affected individuals need to develop psychological mechanisms enabling them to adapt to the disease in the best way possible. Therefore, numerous studies have been undertaken to investigate factors that determine levels of adaptation to living with a chronic disease across a range of medical conditions [
Destroy user interface control50], including psoriasis [
Destroy user interface control13]. Social support is an important aspect of social relationships which is strongly implicated in the process of adaptation to ones own disease [
Destroy user interface control27]. Social support serves to satisfy the persons needs, particularly in difficult, critical circumstances, through the relationships with significant persons and reference groups [
Destroy user interface control52].
Several types of social support have been differentiated [ The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version.
Destroy user interface control53]. In the context of adaptation to disease, Sk and Cielak [
Destroy user interface control43] identified five types of social supports: instrumental, informational, tangible, emotional and spiritual. Instrumental support involves provision of advice and other indirect means enabling the person to cope more effectively with a stressful situation. These can be, for example, the instructions on how to cope with a given problem, or how to behave in a situation. Informational support is understood as provision of disease- or health-relevant information for a patient. Such information can be obtained from professional (e.g. doctors, nurses and the scientific literature) or from non-professional sources (e.g. other patients, superstitions) and helps the patient understand better his/her health-related situation. Tangible support consists in obtaining material help, for example financial aid, or other necessary goods. Emotional support involves evoking the feelings and emotional states in the patient which can relieve the patients negative affect and through this facilitate coping with the disease on the emotional level. Spiritual support involves those actions of other people (e.g. a minister, a prayer group) which help the patient to attribute a deeper, spiritual meaning to their disease or suffering. Globally, thus, disease-related social support is the amount of emotional and spiritual care, tangible and instrumental aid, and information, perceived as available for an individual when coping with the disease [
In contrast to other clinical populations, strikingly few studies investigated the role of social support in patients with psoriasis [ The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version.
Destroy user interface control37]. This seems odd, since social factors have been reported as particularly essential in adaptation to this disease. For instance, social stigma and social rejection were shown to exert strong negative impact on psychosocial functioning in psoriasis patients [
Destroy user interface control22]. Additionally, living with psoriasis was linked to high psychosocial stress, and social domains of quality of life were reported as remarkably strongly compromised in these patients [
Destroy user interface control29]. Disruptions of social interactions, even with the close ones, were also reported to occur due to psoriasis [
Destroy user interface control1]. Therefore, it seems plausible that provision of social support may be of particular importance for this group of patients, which has already been suggested by a recent study on support from online psoriasis communities [
Still less is known about potential gender differences in the links between social support and adaptation to the disease. Gender was a rarely controlled variable in such studies even though general social support research indicated the women had wider social networks than men, had more psychosocial resources available to them [ The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version.
Destroy user interface control15], and reported higher levels of perceived social support then men [
Destroy user interface control51]. To our knowledge, no studies so far investigated gender differences in the impact of social support on adaptation to psoriasis.
The objective of our study was to evaluate the associations between perceived social support and selected indices of adaptation to the disease in patients with psoriasis. We hypothesised that social support could have impact on such indices of adaptation as health-related quality of life, acceptance of life with the disease and depressive symptoms. We also undertook to investigate gender differences in the associations between social support and the indices of adaptation to life with psoriasis. Additionally, we controlled for the effects between psoriasis-related clinical variables on the one hand, and social support and other psychosocial variables on the other hand.
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Materials and methods
Participants
Overall, 113 patients with psoriasis took part in the study. The recruitment procedure involved approaching alternately each consecutive male and female patient admitted to the Dermatology Clinic, to ensure equal sex distribution across the sample. Data from nine patients were excluded due to a failure in completing the questionnaires or sizeable missing data. All patients were thoroughly informed about the goal and conditions of the participation in the study and written informed consent for participation was obtained from all patients. The final study sample consisted of 104 patients with psoriasis vulgaris who were hospitalised between November 2007 and May 2008 at the Dermatology Clinic in Lublin, Poland. Fifty-two were males and 52 were females. Upon enrollment, information was collected for each patient on age, gender, marital status, education, employment status, disease duration, occurrence of lesions on readily visible versus possible to cover body areas, number of hospitalizations, co-existence of other diseases and residence with or without family. Severity of the illness was estimated by means of the Psoriasis Area and Severity Index (PASI) and percent of lesional skin. PASI is a well-established standard measure of psoriasis severity combining the severity of psoriasis symptoms (erythema, infiltration and desquamation) and percent of lesional skin into one numerical index [ The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version.
Destroy user interface control14]. The evaluation of the disease severity was always done by one researcher (G. Ch.) to avoid inter-rater error variance.
Psychological testing
Each patient was requested to fill in a battery of psychological questionnaires. The questionnaires were distributed by one of three researchers (A.P., I.G. and .K.) to the patients
during their stay at the ward. The researcher provided the patient with a standard instruction on how to fill in the questionnaires. The following psychological measures were applied: Acceptance of Life with the Disease Scale, developed by Janowski and Steuden, is a 20-item self-report questionnaire measuring an overall level of adaptation to the disease, understood as the ability to reconcile with the disease and retain overall satisfaction with life in spite of the disease burden. People who score high on this scale are also able to distance themselves from their disease and its symptoms. In the standardisation study, reliability of this instrument was found to be high: Cronbachs alpha = 0.91 and split-half reliability = 0.94. Factor analysis yielded three factors: (1) satisfaction with life (nine items, Cronbachs alpha = 0.90), (2) reconcilement with the disease (six items, Cronbachs alpha = 0.80) and (3) self-distancing from the disease (five items; Cronbachs alpha = 0.69). Respondents answer to the statements on a 4grade scale, ranging from 1 to 4. The total scores can theoretically range from 20 to 80, with higher scores indicating greater acceptance of life with the disease. The full contents of this instrument are in the Appendix. Disease-Related Social Support Scale, developed by Brachowicz, Janowski and Sadowska [ The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version.
Destroy user interface control6], consists of 30 self-report items developed to measure perceived levels of social support available for the patient over the period of their being ill. The scale consists of five subscales corresponding to five types of social support distinguished by Sk and Cielak [
Destroy user interface control43]: instrumental, informational, tangible, emotional, and spiritual support. All subscales composed of six items and have satisfactory reliabilities: (1) spiritual support (Cronbachs alpha = 0.87), (2) instrumental support (Cronbachs alpha = 0.85), (3) informational support (Cronbachs alpha = 0.86), (4) tangible support (Cronbachs alpha = 0.84) and (5) emotional support (Cronbachs alpha = 0.86). The total score, indicative of the overall perceived support, is a sum of the scores from the subscales, with Cronbachs alpha = 0.94 and split-half reliability = 0.92. Respondents provided answers to the statements on a 4-grade scale, with higher scores suggesting higher levels of perceived social support. Exemplary items are given below:
I am informed about my health state, as I need it. There are people who teach me how to solve problems. There are people willing to give me financial support when I need it.
Other people console me if I need it. There are people who assist me with searching for meaning of life in my disease. Skindex-29 is a self-report questionnaire developed by Chren et al. [ The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version.
Destroy user interface control8] measuring health-related quality of life in patients with skin diseases. The instrument consists of three subscales: physical symptoms, functioning and emotions. The patients respond on a 5-point scale, higher scores indicate poorer quality of life. The theoretical range of the scores is from 29 to 145. The questionnaire had been adapted and validated in the Polish sample with resulting very good psychometric properties resembling those reported for the original American version, with Cronbachs reliability coefficient for the total score alpha = 0.96. The reliability coefficients for the subscales are as follows: physical symptoms (Cronbachs alpha = 0.80), functioning (Cronbachs alpha = 0.92) and emotions (Cronbachs alpha = 0.93) [
Destroy user interface control46]. Physical symptoms cover different subjective complaints related to skin, such as burning, itching, bleeding, or pain. The functioning scale measures the negative impact of a skin disease on different everyday activities, including quality of sleep, work, hobby, social relationships, closeness to others and self-exclusion from social participation. Emotions include subjective emotional experience of fears, depression, worries about appearance, anger, embarrassment, frustration, humiliation and irritation.
Beck Depression Inventory (BDI): is one of the most commonly world-wide used self-report instruments measuring levels of depressive symptomatology. The inventory consists of 21 categories of depressive symptoms, and the subject is requested to select the response within each category that describes best his/her mental condition. BDI yields the scores ranging theoretically from 0 to 63, with higher scores indicating more severe depressive symptomatology. The usual threshold for detection of depression is the score of 12 [ The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version.
Destroy user interface control3]. Most of the researchers report alpha coefficients higher than 0.75, the average coefficient for psychiatric samples amounts to 0.88, and for the nonpsychiatric samples is 0.82 [
Statistical analyses
Descriptive statistics are presented as mean and standard deviations (M SD). Smirnoff Kolgomorov test was used to check for normal distribution of the variables. Since the distribution of the disease-related social support scale scores was significantly different from the normal distribution, non-parametric statistical tests were applied in further analyses. Spearmans rho correlations were calculated to assess associations between social support and other psychological variables. The correlations were calculated separately for men, women and for the total sample. Regression analysis was applied to explain the participation of particular social support dimensions in accounting for the variance in the indices of adaptation to the disease (acceptance of life with the disease, depressive symptoms, and quality of life). Cluster analysis (k means method) was used to identify the subgroups of patients homogeneous with respect to overall adaptation to disease, and analysis of variance was applied to compare the mean scores on social support dimensions between the identified subgroups. The level of statistical significance was set at 0.05.
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Results
Clinical and psychological characteristics of the sample

At the time of the study, subjects were aged between 15 and 73 (M = 45.6, SD = 14.24). The disease duration ranged from 1 month to 52 years (M = 18.68, SD = 13.31). The scores on the PASI scale were in the range of 7 to 43.5 and were indicative of moderate to severe psoriasis. The mean PASI score was 24.04 (SD = 5.34). The percent of lesional skin ranged from 0.5 to 75 % (M = 30.81, SD = 14.12). The life-time number of previous hospitalizations due to psoriasis was from 0 to 65 (M = 10.38, SD = 13.79). Skin lesions were located on uncovered body areas (head, face, neck and hands) in 75 % of the patients, and on body parts possible to cover with clothes in 25 % of the patients. Eighty-nine percent of patients reported living with family, and 11 % lived alone. No statistically significant gender differences were found for social support or acceptance of life with the disease. Statistically significant differences were observed between men and women only on depressive symptoms (MannWhitney test z = 2.27, P = 0.018) and on the emotions dimension of quality of life (MannWhitney test z = 2.02, P = 0.044), where women scored
significantly higher than men, suggesting more severe depressive symptoms and worse quality of life in the domain of emotions.
Psoriasis severity and psychosocial variables

The clinical characteristics of psoriasis severity (the PASI score, number of hospitalizations, percent of lesional skin and disease duration) were found to be unrelated to depressive symptoms (BDI score) both in the total sample and in the samples of men and women. Similarly, no statistically significant correlations were observed between severity of psoriasis and acceptance of life with the disease in either sample. In the total sample, out of psoriasis severity indices, only disease duration was significantly negatively correlated with one dimension of social support instrumental support (r = 0.20), P = 0.044). In the total sample, the percent of lesional skin was correlated with the global index of quality of life (r = 0.27, P = 0.006), functioning (r = 0.30, P = 0.002), and emotions (r = 0.23, P = 0.019), and PASI was correlated with functioning (r = 0.27, P = 0.033). In females, disease duration correlated with instrumental support (r = 0.30, P = 0.030) and with physical symptoms (r = 0.28, P = 0.045). In males, PASI was significantly related to quality of life: global index (r = 0.32, P = 0.030), functioning (r = 0.35, P = 0.016) and emotions (r = 0.34, P = 0.020). In males, also percent of lesional skin was correlated with the same indices of quality of life: global index (r = 0.40, P = 0.003), functioning (r = 0.40, P = 0.003) and emotions (r = 0.39, P = 0.005).
Social support and adaptation to the diseasecorrelational analysis

The global level of perceived social support was found to be significantly positively related to acceptance of the disease in the whole sample, and both in men and women. The association between these variables was slightly stronger for men than for women. All dimensions of social support were statistically significantly related to acceptance of the disease, when calculated for the whole sample. Considerable differences between men and women were uncovered with respect to the correlations of tangible and emotional support with acceptance of the disease: these associations were much stronger for men (Table 1).
Table 1 Spearmans rho correlations between social support, and acceptance of the disease and depressive symptoms
The global index of social support was found to be significantly negatively related to levels of depressive symptomatology when analyzed in the whole sample and in the women group. This
association, however, was found statistically insignificant for men. The correlations between particular dimensions of social support and depressive symptoms were generally stronger for women than for men (except for emotional support). The strongest association was observed between tangible support and depressive symptoms: for the total sample and both men and women. The most noticeable differences between men and women were found with respect to the impact of informational and instrumental support on depression, with these links significantly stronger for women than for men (Table 1). The global index of social support was found to be significantly inversely correlated with the global index of quality of life in the whole sample, indicating that higher levels of perceived social support tend to co-occur with lower decrements in health-related quality of life. This tendency was also true for women but not for men. In men, the relationship between the global index of social support and quality of life was statistically insignificant. The strongest associations were observed between the dimension of tangible support and quality of life, and this was true both for women and men, although the strength of the relationship was considerably greater in women. Some interesting gender differences were also found with respect to spiritual, informational and emotional support (Table 1).
Social support and adaptation to the diseaseregression analysis

Regression analysis was applied to identify social support dimensions most significantly accounting for the variance in acceptance of life with the disease, depressive symptoms and quality of life. We carried out a series of regression analyses separately for each index of adaptation to the disease. In each case, we first entered gender as an independent variable (males were coded as 0 and females as 1) and in the second block all dimensions of social support were entered. In this way, we could control separately for the effects of gender and each factor of social support. The obtained results of the regression analyses are presented in Table 2.
Table 2 The stepwise regression analysis models explaining the variance in the indices of adaptation to life with psoriasis
The global index of acceptance of life with psoriasis was statistically significantly accounted for only by tangible support (approximately 19 % of explained variance). Gender turned out to be insignificant both alone and in combination with social support dimensions. For two dimensions of acceptance of life with the disease: reconcilement with the disease and self-distancing from the diseasethe same finding was obtained, namely, in both cases only tangible support but not
gender was found to be statistically significant. In the case of satisfaction with life, the percent of explained variance was higher (approximately 28 %) and two dimensions of social support reached statistical significance, namely tangible support and informational support. Tangible support was found to be associated with the global score of acceptance of life with the disease positively, and similarly, informational support was positively linked to satisfaction with life, which means that higher levels of perceived tangible and informational support are predictor of better acceptance of life with the disease (Table 2). Regression analysis for depressive symptoms revealed that both gender and tangible support were statistically significant in accounting for the variance of this variable and they explained together 23 % of variance. The analysis revealed that the female gender was predictive of higher depressive symptoms whereas higher tangible support levels were related to lower depressive symptoms. Other social support dimensions did not reach the statistical significance level. Regression analysis for quality of life indicated that tangible support was the only support factor significantly accounting for the variance in all indices of quality of life (the global score, physical symptoms, functioning and emotions). For the global quality of life score, the regression model accounted for approximately 19 % of the variance. In the quality of life domain of emotions, gender was found as a second independent variable significantly contributing to the variance in this variable (approximately 20 % of explained variance). For the domains of physical symptoms and functioning, tangible support was the only variable contributing significantly to the variance. Higher scores on the quality of life scale (lower quality of life) were associated with lower tangible support, and in the case of emotions, female gender was related to lower quality of life (Table 2).
Social support and adaptation to the diseasecluster analysis

In the next step of the analysis, we proceeded to distinguish the subgroups of psoriasis patients differing with respect to their overall adaptation, taking into account simultaneously all three indices of adaptation. We applied hierarchical cluster analysis (the k means method) on the global scores from Acceptance of Life with the Disease Scale (acceptance), Beck Depression Inventory (depressive symptoms) and Skindex (quality of life). As a result, we obtained three different subgroups of patients which we labelled adapted (N = 26), moderately adapted (N = 43) and maladapted N = 35). The mean profiles for the subgroups are presented in Fig. 1. Before entering the data into cluster analysis, we linearly transformed the scores on the three scales into standardised z scores, to enable their direct comparison.
Fig. 1
Mean profiles of adaptation indices for three groups of psoriasis patients identified in cluster analysis (Adapted, N = 26; moderately adapted, N = 43; maladpated, N = 35). The total scores on Acceptance ...
The adapted group was characterised by the highest scores on acceptance of life with the disease, lowest on depressive symptoms and had highest levels of quality of life (low scores on Skindex indicate high quality of life). The moderately adapted group showed average levels of both acceptance of life with the disease, depressive symptoms and quality of life. The maladapted group scored lowest on acceptance of life with the disease, highest on depressive symptoms and revealed the lowest levels of quality of life (high scores on Skindex). The identified subgroups were then compared on their reported levels of social support dimensions (Table 3). Analysis of variance evidenced statistically significant differences between the compared groups for all dimensions of social support, with an exception for emotional support where only a statistical trend was observed (P = 0.097). The subgroups with higher levels of overall adaptation to the disease also reported higher levels of social support. Post hoc tests showed that the most pronounced differences were observed for the adapted and maladapted subgroups, no statistical differences were found, however, between the adapted and moderately adapted subgroups. The most significant differences were observed for tangible support (F = 9.13) and global support (F = 6.01).
Table 3 Mean scores, standard deviations and differences between the groups of adapted, moderately adapted and maladapted patients on perceived social support Go to:
Discussion
The objective of this study was to explore the associations between social support and selected indices of adaptation of the disease in patients with psoriasis. Gender differences in these relationships were also addressed. The results of the initial analyses showed that the women and men with psoriasis reported similar levels of perceived social support. This finding is somewhat different from some other studies which indicated that women tend to perceive higher levels of social support than men [
The findings from the correlational analysis showed that higher levels of global perceived social support were related to better acceptance of life with the disease in both men and women with psoriasis. Among different dimensions of social support, tangible support was found to be most closely related to better acceptance of life with the disease in the whole group, and this was particularly significant for men. This strong link can be probably accounted for by essential importance attributed to material security by patients with psoriasis. Some studies emphasised a burdensome impact of psoriasis on economic quality of life [ The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version.
Destroy user interface control31] which may explain why tangible support proved to be most closely related to acceptance of life with psoriasis. Interesting gender differences were found with respect to three dimensions of social support: spiritual, tangible and emotional support. These social support dimensions were clearly more closely related to better acceptance of life with psoriasis in men than in women. These differences may result from the fact that mens satisfaction with life, including the life with psoriasis, is dependent on social acceptance, social recognition and material status to a greater extent than that of womens [
Destroy user interface control39]. It should be mentioned that one study found that gender had no effect on acceptance of psoriasis [
Destroy user interface control54] although this study did not explore the impact of gender on the relationship between social support and acceptance of the disease.
Higher global levels of social support were also significantly correlated with lower depressive symptoms, although this correlation was found to be statistically significant only in women. Therefore, social support may be viewed as a buffer for emotional disturbances revealed under the form of depressive symptomatology in women with psoriasis, whereas this effect may be insignificant for men with psoriasis. The differences within this effect between men and women were particularly strong for instrumental and informational support, which suggests that women profit better from these types of support in terms of prevention of depressive symptoms. In one study, social support was reported to be related to lower depression even irrespective of gender [ The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version.
Destroy user interface control16]. However, our findings linking higher social support with lower depression in women whereas to a lesser degree in men are corroborated by findings from some other studies. For instance, gender differences were reported with respect to anxiety in a study on the influence of social support on adaptation to surgery. Women declaring high informational support exhibited lower anxiety levels, whereas men showed low anxiety even when deprived of informational support [
Destroy user interface control30]. We hypothesise that informational and instrumental types of support may make women, but not men, feel more in control of the situation, increase the controllability of the disease as a stressor, reduce helplessness, which in turn diminishes the risk of development of depressive symptoms. Similar explanations were proposed for patients with major depressive disorder and dysthymia [
It is of note that tangible and emotional supports were the only social support dimensions that were significantly related to lower depressive symptoms in men, and the same two dimensions were important for men with respect to better acceptance of the disease. This suggests that these two social support dimensions correspond with two levels of sense of security in men: tangible and emotional security. We believe that the presence of tangible and emotional support favours better acceptance of life with the disease and buffers development of depressive symptoms in men. In contrast, all types of social support buffer depressive symptoms in women. Therefore,
disturbed access to one social support dimension may be less detrimental for women because it may be more easily compensated by profiting from other remaining accessible social support dimensions. In line with our explanatory hypotheses, some other researchers also reported that social support had a stronger buffering effect on depressive symptoms in females than in males [ The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version.
Destroy user interface control33]. Similarly, Hann et al. [
Destroy user interface control23] also reported that in a sample of cancer patients, larger social support network was associated with less severe depression for women but not for men.
Gender differences in the relationship between social support and depressive symptoms implicate that social support will be generally more effective in prevention of depression for women than for men with psoriasis; therefore, psychosocial interventions for psoriasis patients should be gender specific. It is of particular importance in light of data from other studies that women from various clinical populations, including psoriasis patients, generally score higher on depression measures than men [ The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version.
Destroy user interface control5]. Therefore, provision of instrumental and informational support for patients with psoriasis, especially for women, should be taken into consideration when planning psychosocial education. In contrast, men should be sensitised on how to utilise instrumental and informational support in order to optimise their adaptation to psoriasis.
Some studies reported that men had higher health-related quality of life than women [ The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version.
Destroy user interface control17] although in our study patients with psoriasis did not show gender differences on the global index of quality of life. However, men did show better quality of life than women in the domain of emotions. The analysis of correlations between social support and quality of life showed that higher global index of support was related to higher quality of life in the total sample and in women, but not in men. When analyzing individual dimensions of support it was found that the global index of quality of life was related to instrumental and
informational support in women but not in men. Global quality of life was correlated with emotional and spiritual support in men but not women, whereas with tangible support both in women and men. Again, among all support dimensions, the strongest relationship to quality of life was observed for tangible support. It is also of note that informational support was relatively strongly related to quality of life in women but it was entirely insignificant for quality of life in men. Therefore, it can generally be claimed that quality of life in patients with psoriasis is related to perceived social support but this relationship is also mediated by gender, and the protective effects of support on quality of life are generally more noticeable in women. Our findings differ somewhat from those reported by Gallicchio et al. [
Destroy user interface control17] who observed that health-related quality of life in a community-based sample was correlated with social support but this relationship was not mediated by gender. The differences between the latter and our study can, however, be attributed to a different type of sample (clinical vs. community based) and to a different conceptualization of social support (functional vs. structural approach).
The findings from regression analyses we conducted for the indices of acceptance of life with the disease, depressive symptoms and quality of life confirmed again the most critical role of tangible support for all these indices of adaptation to psoriasis. Some other studies also indicated the importance of tangible support for adaptation to a chronic disease. Symister and Friend [ The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version.
Destroy user interface control47] reported that tangible support was an important predictor of an increase in optimism in a sample of patients with renal failure. In another study, tangible support together with self-efficacy was independent predictors of mental health status in patients with myasthenia gravis [
On the basis of cluster analysis, three types of patients were identified with different levels of overall adaptation to psoriasis: adapted, moderately adapted and maladapted. It is of note that this classification combined the global scores on all the applied measures of adaptation to the disease. Therefore, this classification probably corresponds best to overall adaptation of these patients to living with psoriasis. When compared on the dimensions of support, these subgroups were found to differ significantly on all dimensions of social support. Two observations seem
particularly interesting. First, the groups with decreasing levels of adaptation presented systematically lowered levels of perceived social support. Second, tangible support and global support were the most strongly differentiating factors although the most pronounced differences between the subgroups were again found for tangible support. The general conclusion from this part of analysis is that when the indices of adaptation to the disease are combined, all dimensions of support reach the significance level.
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Conclusion
Certain previous studies reported that women were more inclined than men to look for social support [ The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version.
Destroy user interface control44] and to benefit from social support when coping with stress [
Destroy user interface control38]. In the light of our findings, the overall picture seems a little more complex. We have demonstrated that social support may exert
diverse impact on different indices of adaptation to the disease and these effects are additionally mediated by gender.
In the case of our patients with psoriasis, gender differences in adaptation to the disease may be accounted for also by social factors influencing self-perception and social appearance in particular. Social, psychological, cultural and biological factors contribute to the concept of gender, and these factors may influence illness behaviour [ The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version.
Destroy user interface control49]. Psoriasis is an illness closely related to appearance concerns, and therefore, the buffering impact of social support on depression and quality of life in women with psoriasis may be mediated through a decrease in appearance concerns and increase in feelings of social acceptance. In future, further studies should probably pay more attention to the social context of this disease to unravel the exact nature of the relationship between social support and adaptation to psoriasis.
Generally, the findings from this study confirm previous results indicating that higher social support may have beneficial effects on adaptation to life with the disease. What is more interesting, however, our study emphasises that the strength of these effects may be gender related. Additionally, gender differences regarding the impact of social support on adaptation to life with a chronic disease, such as psoriasis, may strongly depend on the type of selected indicator of adaptation. A detailed analysis of the mutual relationships between different dimensions of social support and different indicators of adaptation to life with the disease can reveal specific pathways through which social support affects how well men and women adapt to their chronic disease.
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Acknowledgments
The study was partially funded by statutory funds for research granted to Department of Clinical Psychology, John Paul II Catholic University of Lublin (study no. 1/6-1-11-05-2274) and research fund no. 164/2010 granted to Prof. Grayna Chodorowska.
Conflict of interest
The authors declare that they have no conflict of interest.
Open Access
This article is distributed under the terms of the Creative Commons Attribution License which permits any use, distribution, and reproduction in any medium, provided the original author(s) and the source are credited.
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Psychiatric Issues in Dermatology, Part 1: Atopic Dermatitis and Psoriasis

James L. Levenson, MD
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Primary Psychiatry. 2008;15(7):35-38
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Curren CME Ar Non-CM
eimer's Dr. Levenson is professor in the Departments of Psychiatry, Medicine, and Surgery, chair of the ase Summit
ived Issues
Division of Consultation-Liaison Psychiatry, and vice chair for clinical affairs in the Department of Psychiatry at Virginia Commonwealth University School of Medicine in Richmond.
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Disclosure: Dr. Levenson reports no affiliation with or financial interest in any organization that may pose a conflict of interest.
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This column begins a series reviewing the interface between dermatology and psychiatry. Dermatologists and primary care physicians frequently encounter important psychiatric issues affecting diagnosis and management of patients with dermatologic complaints. Psychiatrists contend with frequent pruritus and rashes in their patients. A study of psychiatric inpatients excluding those with known skin diseases found that 33% of patients reported itching.1 Psychological factors affect numerous dermatologic conditions including atopic dermatitis, psoriasis, alopecia areata, urticaria and angioedema, and acne vulgaris. Some dermatologic conditions are best considered as idiopathic functional disorders such as idiopathic pruritus, which can be generalized or focal (eg, pruritus ani, vulvae, scroti). Some primary psychiatric disorders present with primarily physical symptoms to dermatologists, including body dysmorphic disorder (BDD) and delusional disorder, somatic type (eg, delusions of parasitosis, delusions of a foul body odor). Indeed, most patients with delusions of parasitosis or BDD avoid visiting psychiatrists or other mental health professionals and resist referral. In addition, dermatologists see patients with compulsive behaviors that may be part of obsessivecompulsive disorder or stand alone (eg, trichotillomania, psychogenic excoriation, onychophagia). Factitious skin disorders include factitious dermatitis (ie, dermatitis artefacta) and psychogenic purpura. Another important aspect of the interface between psychiatry and dermatology is the range of dermatologic adverse reactions to psychotropic drugs. More detailed coverage of these topics can be found elsewhere.2,3 This part of the series focuses on atopic dermatitis and psoriasis.
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Atopic Dermatitis
Atopic dermatitis (ie, atopic eczema) is a chronic skin disorder characterized by pruritus and inflammation (ie, eczema), starting as an erythematous, maculopapular rash. Scratching is hard to resist and leads to excoriation and secondary infection, resulting in lichenification. Atopic dermatitis is the most common inflammatory skin disease of childhood and remains fairly common in adults. It typically begins in children or adolescents with a personal or family history of atopic dermatitis, allergic rhinitis, or asthma. In most patients, atopic dermatitis is a recurrent, relapsing disorder, with a vicious cycle of itching and scratching that leads to chronicity.
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Atopic Dermatitis and Stress

The onset or exacerbation of atopic dermatitis often follows stressful life events.4,5 Divorce or separation of parents and severe disease of a family member have been identified as particularly increasing risk.4 Adults with atopic dermatitis are more anxious and depressed compared with clinical and healthy control groups.6,7 Children with atopic dermatitis have higher levels of
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emotional distress and more behavioral problems than healthy children or children with minor skin problems.
Psychosocial Morbidity in Atopic Dermatitis

Atopic individuals with emotional problems may develop a vicious cycle between anxiety/depression and dermatologic symptoms. In one direction of causality, anxiety and depression are frequent consequences of the skin disorder. The misery of living with atopic dermatitis may have a profoundly negative effect on health-related quality of life (HRQOL) of children and their families. Intractable itching causes significant insomnia, and sleep deprivation leads to fatigue, mood lability, and impaired functioning. Teasing and bullying by children and embarrassment in adults and children can cause social isolation and school avoidance. The social stigma of a visible skin disease, frequent visits to doctors, and the need to constantly apply messy topical remedies all add to the burden of disease. Lifestyle restrictions in more severe cases can be significant, including limitations on clothing, staying with friends, owning pets, swimming, or playing sports. The impairment of quality of life caused by childhood atopic dermatitis has been shown to be greater than or equal to that of asthma or diabetes.8 In the other direction of causality, anxiety and depression aggravate atopic dermatitis. This may occur via several possible mechanisms, including modulation of pruritus perception,9 perturbation of epidermal permeability barrier homeostasis,10 or acceleration of immune responses.6
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Psychiatric and Psychological Treatments for Atopic Dermatitis

A wide variety of treatments for atopic dermatitis have been advocated to interrupt the vicious cycle of itching and scratching. Mental health interventions include psychological, behavioral, and psychoeducational therapies and psychotropic medications. There have been several randomized controlled trials of psychological and educational interventions (eg, relaxation training, habit reversal training, cognitive-behavioral techniques, stress management training) as an adjunct to conventional therapy for children with atopic eczema to enhance the effectiveness of topical therapy, but the evidence base remains limited regarding their efficacy.11 Oral and topical doxepin have been used because its potent antihistaminic effects can reduce itching, and oral doxepins sedation can promote sleep. A systematic review of controlled trials12 of 47 different interventions concluded that there was reasonable evidence to support the use of oral cyclosporine, topical corticosteroids, psychological approaches, and ultraviolet light therapy. However, there was insufficient evidence to make recommendations regarding oral or topical antihistamines (eg, doxepin), maternal allergen avoidance for prevention, dietary restriction in
Determ Malinge Disabili Evaluat
Psychia in Endo
Submit Letters
established atopic dermatitis, hypnotherapy, and a variety of other orthodox and alternative medical interventions.
Psoriasis
Psoriasis is a chronic, relapsing disease with characteristic scaly lesions varying from pinpoint plaques to extensive skin involvement, nail dystrophy, and often arthritis. Psoriasis is an equally common condition among men and women, affecting 1.5% to 2% of the population in industrialized countries, with onset usually in the third decade of life. Most patients with psoriasis experience unpredictable exacerbations throughout life. The pathogenesis of psoriasis appears to involve genetic and environmental factors, influencing the bodys systems of skin repair, inflammatory defense mechanisms, and immunity.2,3
Psoriasis and Lithium

A particular concern for psychiatrists is lithium-induced psoriasis, which typically occurs within the first few years of treatment. Male patients taking lithium appear to be more susceptible to developing cutaneous reactions to lithium than females. Even a very small amount of psoriasis can be distressing to patients and can undermine medication compliance. Lithium-induced psoriasis is sometimes resistant to psoriatic treatments but resolves after discontinuation of lithium.13 There have also been case reports of psoriasis precipitated or aggravated by olanzapine.14,15
Psychosocial Morbidity in Psoriasis

Psoriasis is associated with a variety of psychological difficulties, including poor self-esteem, sexual dysfunction, anxiety, depression, and suicidal ideation. Psoriasis is associated with substantial impairment of HRQOL, negatively impacting psychological, vocational, social, and physical functioning.16 Not surprisingly, appearance-related concerns dominate the experiences of young people with psoriasis.17 A theme running through the psoriasis literature is conveyed in the conclusion from a systematic review of psychosocial burden of psoriasis: Social stigmatization, high stress levels, physical limitations, depression, employment problems 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.18 A recent cross-sectional study19 of 265 adults with prevalent psoriasis found that 32% of
subjects screened positive for depression, with a graded relationship between depressive symptoms and impairment of HRQOL. Only 16.5% of those with high depression scores were receiving treatment for the condition. Depression was highly associated with both illness-related stress and dissatisfaction with antipsoriatic treatment. It was not associated with objective measures of psoriasis severity.19 A survey of 2,391 Italian adults with psoriasis using the Center for Epidemiological Studies-Depression Scale questionnaire found 62% of patients presenting depressive symptomatology. There was no difference in gender; however, younger men were more likely to report depressive symptoms than older men as were all subjects with less education.20 The emotional effects and functional impact of the disease are not necessarily proportionate to the clinical severity of psoriasis.21 In general, psychological factors, including perceived health, perceptions of stigmatization, and depression, are stronger determinants of disability in patients with psoriasis than are disease severity, location, and duration.22 It is not surprising that perceived stress in patients with psoriasis as well as numerous chronic diseases predicts poorer quality of life.23 Studies of the relationship between psychological factors and psoriatic disease severity have been primarily focused on depression. Some investigators found the condition correlated with objective measures of psoriasis severity24 and others have not.19 In a large double-blind, placebo-controlled trial of etanercept,25 which is an effective treatment for the clinical symptoms of psoriasis, patients who received etanercept had significant improvement in both fatigue and depressive sympomatology. Improvement in fatigue was correlated with decreasing joint pain, but improvement in depressive symptomatology was less correlated with objective measures of skin clearance or joint pain. In a recent prospective study of patients with psoriasis,26 the frequency of psychiatric disturbance decreased with improvement in the clinical severity and symptoms of psoriasis. Other predictors of psychiatric improvement included no psoriatic involvement on the face and sex (ie, women were less likely to improve psychologically). However, the authors concluded that dermatologists should be aware that even in the presence of vast clinical improvement patients may still substantially suffer psychologically.26
Psoriasis and Suicide

In addition to the effects of depression on possibly triggering psoriasis and certainly reducing disease-related quality of life, suicide is a concern. One study found that 10% of adults with psoriasis reported suicidal ideation during the previous 2 weeks.27 Gupta and Gupta28 reported suicidal ideation in 2.5% of psoriasis outpatients and 7.2% of inpatients. In an earlier study of a different sample, Gupta and colleagues29 found that 9.7% of patients with psoriasis reported a wish to be dead, and 5.5% reported active suicidal ideation at the time of study. Death wishes and suicidal ideation were associated with higher depression scores and higher patient selfratings of psoriasis severity.
Psoriasis and Stress

Stress has long been reported to trigger psoriasis.2,3 Uncontrolled studies have reported very high rates of stressful life events preceding the onset of the illness (eg, 68% of adult patients in one study,24 and 50% of children and 43% of adults in another).30 However, perception and recall biases influence such rates. A cross-sectional study23 of 141 adults found that approximately 66% strongly believed that stress was a causal factor for their psoriasis. This belief was significantly associated with higher levels of anxiety, depressive symptomatology, and perceived stress, but there was no association between perceived stress objective measures of psoriasis severity. A large case-control study31 comparing 560 patients with psoriasis to 690 patients with a new diagnosis of skin disease other than psoriasis found a high index of stressful life events associated with patients having more than double the risk of psoriasis compared to low scorers. However, the same study found that current and ex-smokers had approximately double the risk of psoriasis. Not all studies have supported the widely held belief that stressful life events precipitate psoriasis. For example, an investigation32 of outpatients experiencing a recent onset or exacerbation of psoriasis found no difference when comparing them to outpatients with skin conditions in which psychosomatic factors are regarded as negligible. Ultimately, however, most patients who report episodes of psoriasis precipitated by stress describe disease-related stress, resulting from the cosmetic disfigurement and social stigma of psoriasis, rather than stressful major life events or nonspecific distress.2,3 In an experimental study, 40 patients with chronic plaque psoriasis and 40 age-matched normal controls were subjected to acute psychological stressors (ie, cognitive, emotional, social). Patients with psoriasis and, in particular, those who believed that their psoriasis was highly stress responsive, were found to exhibit altered hypothalamic-pituitary-adrenal response to acute social stress, specifically lower post-stressor cortisol levels. The implication is that such patients may perhaps be more vulnerable to flares of their psoriasis.33 The mechanism of stressinduced exacerbations of psoriasis has been speculated to involve the nervous, endocrine, and immune systems, but no definitive pathways have been established. A more direct connection may be the effects of anxiety or depressive symptoms in reducing the threshold for pruritus in psoriatic patients.34 The adverse psychological sequelae of psoriasis are often but not always reduced by effective treatment of the disease, as noted in the study of disease-modifying therapy with etanercept cited earlier.25 A study16 that focused on systematic topical treatment for psoriasis found general quality of life significantly improved following treatment. Body image and appearance, selfesteem, and negative feelings were particularly responsive to clinical change. Domains of spirituality, independence and physical health also improved.
Psychiatric and Psychological Treatments for Psoriasis

There have been case reports of dramatic improvement in psoriasis after anxiolytic drug treatment but no controlled studies. The use of psychological therapies for patients with psoriasis has been proposed based on observations that the severity of their disease may correlate with emotional stress. Meditation, hypnosis, relaxation training, cognitive-behavioral stress management, and symptom control imagery training have received support in controlled trials for their effectiveness in reducing psoriasis activity,2,3 but this evidence base is limited by the size and short duration of the studies. A small (n=51) randomized controlled trial35 of a psychological intervention that entailed seven sessions of individual psychotherapy, including stress management, guided imagery, and relaxation, found some evidence of modest benefit on psoriasis activity. A small (n=40) nonrandomized, age- and sex-matched case-controlled psychological intervention trial36 investigating the effects of a cognitive-behavioral psoriasis symptom management program showed significant reductions in illness identity (ie, the frequency and severity of symptoms that patients associate with their condition), the strength of belief in severity of consequences of their illness, and patients attributions for emotional causes of their psoriasis. PP
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The relationship between stress and the onset and exacerbation of psoriasis and other skin conditions
1. M.S. AL'ABADIE1, 2. G.G. KENT2, 3. D.J. GAWKRODGER1
Article first published online: 29 JUL 2006 DOI: 10.1111/j.1365-2133.1994.tb02900.x Issue
British Journal of Dermatology

Volume 130, Issue 2, pages 199203, February 1994 Additional Information(Show All) How to CiteAuthor InformationPublication History
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Summary The role of stressful life events in the progress of various skin conditions was studied retrospectively in patients who presented with either psoriasis (where there is some agreement about the importance of stress), urticaria, acne, alopecia and non-atopic eczema (where there is some uncertainty regarding the role of stress), or malignant melanoma, fungal infection, basal cell carcinoma and melanocytic naevi (where stress is considered less relevant). When patients in the three groups were matched for age, those with psoriasis were more likely to report that the experience of stress pre-dated the onset and exacerbations of their condition than patients with other skin diseases. For the psoriasis patients the most common types of life events were family upsets (such as bereavements), and work or school demands, but chronic difficulties were also common. There was no relationship between the severity of stress and time to onset or exacerbations. The results support the notion that stress is more likely to be associated with the onset of psoriasis than other conditions, but also that there may be considerable individual variation in the ability to cope, suggesting that psychological interventions may be helpful for particular patients.
Common burden of chronic skin diseases? Contributors to psychological distress in adults with psoriasis and atopic dermatitis
1. A.W.M. Evers1,2, 2. Y. Lu1, 3. P. Duller1,2, 4. P.G.M. Van Der Valk2, 5. F.W. Kraaimaat1, 6. P.C.M. Van De Kerkhof2
Article first published online: 22 JUN 2005
DOI: 10.1111/j.1365-2133.2005.06565.x Issue

Volume 152, Issue 6, pages 12751281, June 2005 Additional Information(Show All) How to CiteAuthor InformationPublication History 1. Conflicts of interest: None declared.
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Keywords:

atopic dermatitis; chronic skin diseases; psoriasis; psychological distress; quality of life
Summary
Background Chronic skin diseases, such as atopic dermatitis and psoriasis, are known to affect quality of life by heightening psychological distress. Knowledge about factors contributing to psychological distress is essential for supporting physicians in diagnostic and multidisciplinary treatment options for patients psychologically at risk. Objectives To examine whether generic physical, psychological and social factors relevant to patients with chronic diseases might contribute to psychological distress in adults with psoriasis and atopic dermatitis. Methods Self-report data on clinical skin status, physical symptoms of itching and fatigue, impact of the disease on daily life, illness cognitions and social support were collected from 128 patients with psoriasis and 120 patients with atopic dermatitis (aged over 16 years). Results For patients with either skin disease, clinical status and physical symptoms of itching scarcely affected psychological distress. Instead, higher levels of fatigue, perceived helplessness and less social support best predicted psychological distress in patients with both skin diseases in multiple regression analyses. Conclusions Results demonstrate that generic physical, psychological and social aspects play a role in chronic skin diseases and suggest that multidisciplinary care for patients with psoriasis and atopic dermatitis can be greatly improved by integrating common screening and treatment components for chronic diseases.
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Dermatology 2008;216:8792 (DOI:10.1159/000111504)

Fulltext PDF (186 Kb) Hypotheses and Comments
New Hypotheses in the Genetics of Psoriasis and Other Complex Diseases

Guilhou J.-J. Mols J.-P. Laboratoire de Dermatologie Molculaire, Institut Universitaire de Recherche Clinique, Montpellier, France Dermatology 2008;216:8792 (DOI:10.1159/000111504)
Abstract
Psoriasis is a complex genetic disorder in which the disease, according to the current concept, is caused by the interplay of many different genes. However, recent genetic studies indicate that the location of these genes varies considerably among populations and families, raising the question of how the same phenotype can be induced by such variable genetic linkages. To circumvent these discrepancies we propose that psoriasis could be induced by the same repetitive DNA sequence, an endogenous retroviral element present at different locations in the genome. The occurrence of the disease could be linked to an abnormal activation of one or more endogenous retroviral element copies due to their location and/or to modification of their sequence. This unifying concept would simplify our understanding of genetically complex diseases.
Author Contacts Jean-Jacques Guilhou Laboratoire de Dermatologie Molculaire Institut Universitaire de Recherche Clinique, 641, avenue du Doyen G. Giraud FR34093 Montpellier Cedex 5 (France) Tel. +33 467 415 911, Fax +33 467 542 731, E-Mail dermato@iurc.montp.inserm.fr
Article Information Received: March 15, 2007 Accepted: July 18, 2007 Published online: January 23, 2008 Number of Print Pages : 6 Number of Figures : 0, Number of Tables : 1, Number of References : 64
Publication Details
Dermatology Vol. 216, No. 2, Year 2008 (Cover Date: January 2008) Journal Editor: Saurat, J.-H. (Geneva) ISSN: 10188665 (Print), eISSN: 14219832 (Online) For additional information: http://www.karger.com/DRM
Drug Dosage / Copyright Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in goverment regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher or, in the case of photocopying, direct payment of a specified fee to the Copyright Clearance Center.
Journal of the American Academy of Dermatology Volume 13, Issue 3 , Pages 450-456, September 1985
Psoriasis of early and late onset: characterization of two types of psoriasis vulgaris
T Henseler , E Christophers Abstract
Abstract
In 2,147 patients suffering from psoriasis, evaluation of the age of onset revealed two peaks, one occurring at the age of 16 years (female) or 22 years (males) and a second peak at the age of 60 years (female) or 57 years (males). Human lymphocyte antigen (HLA) tissue typing in 112 randomly assigned patients showed that HLA-Cw6, known to be at disequilibrium in psoriasis, is present in 85.3% of patients with early onset. In contrast, 14.7% patients with late onset showed this marker. Parents (father or mother) were affected in approximately half of the patients with early onset and in none belonging to the group with late onset. Furthermore, psoriasis in patients with early onset follows an irregular course and shows a strong tendency to become generalized. On the basis of clearly defined criteria (e.g., age of onset, heritability, and clinical course of disease), nonpustular psoriasis shows two distinct forms, one of which is hereditary, with early onset, and the other is sporadic and occurs in older age. (J Am Acad Dermatol 1985 Sep;13(3):450-6)
PII: S0190-9622(85)70188-0 1985 Mosby, Inc. All rights reserved.

Look Inside Get Access Find out how to access preview-only content American Journal of Clinical Dermatology December 2005, Volume 6, Issue 6, pp 383-392
The Psychosocial Burden of Psoriasis

Dr Alexa B. Kimball, Christine Jacobson, Stefan Weiss, Mary G. Vreeland, Ying Wu
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Abstract
Background: Skin diseases such as psoriasis can profoundly influence a patients self-image, self-esteem, and sense of well-being. Psoriasis is a multifactorial inflammatory condition with a disease burden that extends beyond the physical symptoms experienced by patients. Psoriasis affects all aspects of quality of life, including physical, psychologic, social, sexual, and occupational elements. Objective: The goal of this article was to review the published literature on the impact of psoriasis on quality of life. Methods: Relevant studies were identified through a comprehensive search of MEDLINE, EMBASE, and the Derwent Drug File databases of English-language articles published between 1993 and 2005 using the terms psoriasis in combination with quality of life, cost, cost-benefit analysis, economic, employment, days lost, healthcare, hospitalization, managed care, outcomes research, occupation, payers, and psychosocial. The reference lists of identified articles were checked for additional studies that might have been missed in the original searches. Results: Data suggest that social stigmatization, high stress levels, physical limitations, depression, employment problems 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. Conclusion: It is essential to include measures of psychosocial morbidity when assessing psoriasis severity and treatment efficacy because of the substantial role that psychosocial burden plays in patient perception of disease severity, quality of life, and disease course.
Ann Rheum Dis 2005;64:ii18-ii23 doi:10.1136/ard.2004.033217
Psoriatic arthritis and psoriasis: classification, clinical features, pathophysiology, immunology, genetics
Psoriasis: epidemiology, clinical features, and quality of life

1. R G B Langley1, 2. G G Krueger2, 3. C E M Griffiths3
+ Author Affiliations
1.
Division of Dermatology, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada 2. 2Department of Dermatology, University of Utah, Salt Lake City, Utah, USA 3. 3Dermatology Centre, University of Manchester, Hope Hospital, Manchester, UK
1. Correspondence to: Dr R G B Langley Division of Dermatology, Department of Medicine, Dalhousie University, 4195 Dickson Building, 5820 University Avenue, Halifax, Nova Scotia, Canada B3H 1V6; rgblangl@dal.ca
Abstract
Psoriasis is a common chronic, recurrent, immune mediated disease of the skin and joints. It can have a significant negative impact on the physical, emotional, and, psychosocial wellbeing of affected patients. Psoriasis is found worldwide but the prevalence varies among different ethnic groups. It has a strong genetic component but environmental factors such as infections can play an important role in the presentation of disease. There are several clinical cutaneous manifestations of psoriasis but most commonly the disease presents as chronic, symmetrical, erythematous, scaling papules and plaques. The epidemiology, clinical features, and impact on quality of life of psoriasis are reviewed.
Life events involvement in psoriasis onset/recurrence

1. Liana Manolache MD, PhD1, 2. Dana Petrescu-Seceleanu MD2, 3. Vasile Benea MD, PhD3
Article first published online: 31 MAY 2010 DOI: 10.1111/j.1365-4632.2009.04367.x 2010 The International Society of Dermatology Issue
International Journal of Dermatology

Volume 49, Issue 6, pages 636641, June 2010 Additional Information(Show All) How to CiteAuthor InformationPublication History 1. No conflict of interest.
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Abstract
Background The purpose of the study was to evaluate the possible role of stress before the onset/extension/recurrence of psoriasis. Patients and method One hundred and sixty-nine outpatients with psoriasis and 169 age and gender matched controls were enrolled. The design was a case-control study (controls had skin diseases with low psychosomatic component). Stressful life events were evaluated using Holmes and Rahes Social Readjustment Rating Scale. Results In the psoriatic group, there was a female predominance (66%) and a median age 47.55 years (SD = 20.32). In all, 10.65% of patients had family history of psoriasis. More than 54% of cases experienced at least one stressful event (47.36% for onset, 63.51% for recurrence/extension), compared with 19.52% of controls (2 = 42.71, P < 0.0001). The odds ratio was 4.92. There was a significant difference in the mean number of stressful events between patients and controls (P < 0.0001). Women with psoriasis vulgaris and men with guttate psoriasis seemed to be more sensitive to stressful events. We divided the events described by Holmes and Rahe into three categories: family, personal, and job/financial problems. Family matters were mentioned by 42.7% of psoriatic patients, statistically significant compared with controls (P < 0.0001). In 35% of psoriatic cases, the stressful event was represented by the illness/death of someone dear. Both personal (25.6%; P = 0.02) and job/financial problems (31.6%; P < 0.0001) were significantly different compared with controls. Conclusions Stressful events could be highly related to psoriasis (especially in recurrences/extensions). Problems related to family are the most often involved with counseling being suggested.
Journal of Psychosomatic Research Volume 57, Issue 5 , Pages 465-471, November 2004
Perceived stress, stress attributions and psychological distress in psoriasis
Catherine J. O'Leary , Daniel Creamer , Elisabeth Higgins , John Weinman
Received 7 October 2002; accepted 5 March 2004.

Abstract Full Text PDF References
Objective
The objective of this study was to measure causal beliefs in individuals with psoriasis and to explore their relationship with perceived stress, quality of life, psychological well-being and psoriasis severity.
Methods
This study was cross-sectional in design, and patients were required to complete validated questionnaires assessing perceptions of illness, quality of life, psoriasis severity, perceived stress and psychological mood. A total of 141 individuals were recruited from two settings: an outpatient skin clinic at King's College Hospital and the Psoriasis Association.
Results
A strong belief in stress/psychological attributes as a causal factor was found in 61% of the sample. This belief was significantly associated with higher levels of anxiety, depression and perceived stress (r.38; P.0001). Perceived stress in this sample was significantly associated with a poorer level of quality of life, higher levels of anxiety and depression (r.27; P.002) but not with psoriasis severity.
Conclusions
The belief that stress is causal was associated with lower levels of psychological well-being. However, there was no association between perceived stress and more objective measures of psoriasis severity. Keywords: Psoriasis, Stress, Illness perceptions, Causal beliefs
Journal of Psychosomatic Research Volume 57, Issue 5 , Pages 465-471, November 2004
Perceived stress, stress attributions and psychological distress in psoriasis
Catherine J. O'Leary , Daniel Creamer , Elisabeth Higgins , John Weinman
Received 7 October 2002; accepted 5 March 2004.

Abstract Full Text PDF References
Objective
The objective of this study was to measure causal beliefs in individuals with psoriasis and to explore their relationship with perceived stress, quality of life, psychological well-being and psoriasis severity.
Methods
This study was cross-sectional in design, and patients were required to complete validated questionnaires assessing perceptions of illness, quality of life, psoriasis severity, perceived stress and psychological mood. A total of 141 individuals were recruited from two settings: an outpatient skin clinic at King's College Hospital and the Psoriasis Association.
Results
A strong belief in stress/psychological attributes as a causal factor was found in 61% of the sample. This belief was significantly associated with higher levels of anxiety, depression and perceived stress (r.38; P.0001). Perceived stress in this sample was significantly associated with a poorer level of quality of life, higher levels of anxiety and depression (r.27; P.002) but not with psoriasis severity.
Conclusions
The belief that stress is causal was associated with lower levels of psychological well-being. However, there was no association between perceived stress and more objective measures of psoriasis severity. Keywords: Psoriasis, Stress, Illness perceptions, Causal beliefs
Age, gender, quality of life and psychological distress in patients hospitalized with psoriasis
1. F. Sampogna1, 2. M.M. Chren3, 3. C.F. Melchi1, 4. P. Pasquini2, 5. S. Tabolli1, 6. D. Abeni1, 7. The Italian Multipurpose Psoriasis Research on Vital Experiences (Improve) Study Group1
Article first published online: 11 SEP 2005 DOI: 10.1111/j.1365-2133.2005.06909.x Issue

Volume 154, Issue 2, pages 325331, February 2006 Additional Information(Show All)
How to CiteAuthor InformationPublication History 1. Conflicts of interest: None declared. A complete list of the IMPROVE investigators who contributed to this study appears in the Acknowledgements.
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Keywords:

age; gender; psoriasis; psychological distress;
quality of life
Summary
Background Psoriasis has a great impact on the quality of life of patients, and the ageing population is an important public health issue. Objectives To investigate whether older patients with psoriasis have a different impairment in quality of life compared with younger patients, considering level of severity, duration of disease, gender and psychological distress. Methods The study was performed between February 2000 and February 2002 at the inpatient wards of the Dermatological Institute IDI-IRCCS, Rome, Italy, in the framework of a large project on clinical, epidemiological, emotional and quality of life aspects of psoriasis (IMPROVE study). This is a hospital-based cross-sectional study, with measures of quality of life (Skindex-29, Dermatology Life Quality Index and Psoriasis Disability Index) and of psychological distress, generic (12-item General Health Questionnaire) and psoriasis-related (Psoriasis Life Stress Inventory), all self-assessed by patients. We compared the mean scores of each quality of life instrument in patients aged <65 years and 65 years, in subsets of patients based on clinical and sociodemographic characteristics. Results We analysed 936 patients hospitalized at IDI-IRCCS with a diagnosis of psoriasis. Quality of life was significantly more impaired in the older group for all the Skindex-29 scales, and psychological distress was higher in older patients. In particular, older women suffering from anxiety or depression had the greatest impairment in quality of life. The results were somewhat different using the other quality of life instruments. Conclusions These results should alert dermatologists that similar levels of clinical severity in psoriasis may be associated with different levels of quality of life and psychological distress of patients. Particular attention should be devoted to older patients, and especially to older women. Tn ti: (2005) Acute guttate psoriasis patients have positive streptococcus hemolyticus throat cultures and elevated antistreptococcal M6 protein titers. Journal of dermatology, 32(2): 91-6
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Psoriasis and Your Eyes

From Lia Tremblay Updated July 04, 2008 About.com Health's Disease and Condition content is reviewed by the Medical Review Board
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Cataract Multifocal Lenswww.isec.myFast Painless Phaco Cataract Remova Small Incision Cataract Surgery Bilberry from New Zealandwww.nzpurehealth.com/bilberryHigh Ingredients NZ Bilberry Low Price, Free Shipping Worldwide Kem Tr Nm Tn Gchoaanhdao.vn/kem-tri-namB m phm tr nm - tn nhang tn gc c tr nm su nm lu nm (LifeWire) - Psoriasis is more than just a skin disease. It can cause joint damage, known as psoriatic arthritis, and it has been linked to cardiovascular risk, including heart attacks. Psoriasis can also affect your eyes.
Eye problems may be directly related to flare-ups around the eyes. But psoriasis can also lead to problems within the eye itself -- problems that when left untreated can cause permanent vision loss. Flare-ups Around the Eyes Although it is relatively rare, flare-ups near the eyes can be especially painful and hard to treat. Scales and dryness may cause the edges of the eyelids to curve up or down, which may produce drying of the cornea or allow the eyelashes to scrape the cornea of the eye. In such cases, the National Psoriasis Foundation recommends the following:

Wash the affected lids and lashes with a mixture of water and baby shampoo. Use an over-the-counter eyelid cleanser, such as OCuSOFT (Cynacon, Richmond, Texas) to remove stubborn scales. Apply a topical immunosuppressant, such as Elidel (pimecrolimus) around the eyes. Elidel is a prescription medication that must be prescribed by your doctor. Have your intraocular eye pressure tested regularly by an ophthalmologist to ensure that topical treatments aren't harming your eyes.
Dermatologists will sometimes prescribe low-potency steroids for use on the eyelids. This is appropriate, but because of the risk of cataracts and glaucoma, patients should not continue use of these steroids beyond the time recommended by their doctor. Protopic (tacrolimus) has also been shown to be very effective for treatment of eyelid psoriasis. Uveitis and Iritis Uveitis and iritis frequently arise as a complication of a disease, such as psoriatic arthritis or lupus, in which the body's immune system attacks its own healthy tissue. Uveitis is an inflammation of the uvea, the middle layer of the eye's surface. The uvea includes the iris, the colored area at the front of the eye. When uveitis is localized at the front of the eye, it's called iritis (or anterior uveitis). Uveitis can also be localized to the ciliary body, which produces aqueous humor -- the fluid that fills the eye. Uveitis can also be localized to the choroid, which is the small blood vessels behind the retina. Symptoms of uveitis can include:

redness in the eye sensitivity to light blurred vision "floaters" in the field-of-vision
pain in the eye
A diagnosis can only be made after an examination by an ophthalmologist, who'll also look for any concurrent problems in the eye, such as cataracts or glaucoma.
Because of the connection between psoriasis and uveitis, your ophthalmologist may want to consult your primary care physician or any specialists you are seeing to determine a treatment plan. In most cases, corticosteroid eye drops given at home will clear any inflammation. In recurring cases, a systemic immunosuppressive drug may be needed to fight the root cause of the inflammation. If other problems -- such as glaucoma or cataracts -- are diagnosed along with uveitis, surgery may be necessary. Early detection and treatment is of the utmost importance. Untreated uveitis can cause irreversible damage to the delicate eye tissue, and it represents the third most common cause of preventable blindness in the nation. How to Cope If uveitis has become a recurring issue, you may find it helpful to reach out to others with the same problem. There are support groups for uveitis, including an online support group hosted by The Ocular Immunology and Uveitis Foundation, which includes instructions on how to adjust the appearance of the site for users with vision loss. 2013 About.com. All rights reserved.
ubject Categories: Clinical Research Journal of Investigative Dermatology (2005) 125, 6167; doi:10.1111/j.0022202X.2005.23681.x
Cigarette Smoking, Body Mass Index, and Stressful Life Events as Risk Factors for Psoriasis: Results from an Italian Case Control Study
Luigi Naldi*, Liliane Chatenoud, Dennis Linder*, Anna Belloni Fortina, Andrea Peserico, Anna Rosa Virgili, Pier Luigi Bruni, Vito Ingordo , Giovanni Lo Scocco**, Carmen Solaroli, Donatella Schena, Annalisa Barba, Anna Di Landro*, Enrico Pezzarossa, Fabio Arcangeli, Claudia Gianni , Roberto Betti***, Paolo Carli, Alessandro Farris, Gian Franco Barabino and Carlo La Vecchia,
1. *Centro Studi GISED, Ospedali Riuniti di Bergamo, Bergamo, Italy; 2. Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy;
3. Clinica Dermatologica, Universit di Padova, Padus, Italy; 4. Clinica Dermatologica, Universit di Ferrara, Ferrara, Italy; 5. 6. 7. 8. 9.
**
Clinica Dermatologica, Universit di Terni, Italy; Ospedale Principale Militare Taranto, Italy; U.O. Dermatologia, Azienda USL 4, Prato, Italy; Clinica Dermatologica, Universit di Torino, Turin, Italy; Clinica Dermatologica, Universit di Verona, Verona, Italy;
10. U.O. Dermatologia, Ospedale di Cremona, Cremona, Italy; 11. U.O.Dermatologia, Ospedale Bufalini, Cesena, Italy; 12. Dipartimento di Dermatologia, Ospedale San Raffaele, Milan, Cremona, Italy;
13. ***Clinica Dermatologica, Ospedale San Paolo, Milan, Italy; 14. Clinica Dermatologica, Universit di Firenze, Florence, Italy; 15. U.O. Dermatologia, Ospedale di Savona, Savona, Italy; 16. U.O. Dermatologia, Dipartimento di Scienza della Salute, Universit di Genova, Genoa, Italy; 17. Istituto di Statistica Medica e Biometria, Universit degli Studi di Milano, Milan, Italy
Correspondence: Dr Luigi Naldi, Centro Studi GISED, Ospedali Riuniti, L.go Barozzi 1, 24100 Bergamo, Italy. Email: luigi.naldi@gised.it Received 1 September 2004; Revised 16 December 2004; Accepted 20 December 2004.
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Abstract
We conducted a casecontrol study to analyse the association of psoriasis of recent onset with smoking habits, body mass index (BMI) and stressful life events. Cases (n=560; median age 38) were patients with a first diagnosis of psoriasis and a history of skin manifestations of no longer than two years after the reported disease onset. Patients with a new diagnosis of skin diseases other than psoriasis (n=690; median age 36) were selected as controls. The risk of psoriasis was higher in ex- and current smokers than in never-smokers, the relative risk estimates (OR) being 1.9 for ex-smokers and 1.7 for smokers. Smoking was strongly associated with pustular lesions (32 patients, OR=5.3 for smokers). The frequency of psoriasis varied significantly in relation to a family history of psoriasis in first degree relatives, BMI (OR=1.6 and 1.9 for over weighted,
BMI 2629, and obese, BMI 30, respectively) and stressful life event score (compared to the lower index quartile, the OR being 2.2 for index values 115). Risk estimates, when taking into consideration the combined effect of these factors with smoking habits, were consistent with a multiplicative model of risk combination with no significant statistical interaction.
Keywords:
body mass index, casecontrol study, family history, life events, psoriasis, risk factors, smoking habits
Abbreviations:
BMI, body mass index; CI, confidence interval; DC, dendritic cells; OR, odds ratio; TNF, tumor necrosis factor It is widely accepted that geneticenvironmental interaction, i.e., multifactorial heredity, plays a role in the development of psoriasis. Although the genetic influence on psoriasis is well established, the role of environmental factors is less precisely defined. Smoking habits, alcohol consumption, diet, body mass index (BMI), stressful life events, and infections have been repeatedly considered as potentially important causative factors (Naldi, 2004). Risk estimates for these potentially modifiable factors are scanty. Such estimates as well as the analysis of the combined effect of exposure variables and the assessment of variations according to specific clinical subtypes are important pieces of evidence that may have both a theoretical value and important practical implication for the management of psoriasis and its disability prevention. We present a casecontrol study involving newly diagnosed cases of psoriasis and controls with newly diagnosed dermatological conditions other than psoriasis. The aim of the study was to analyze smoking habits and other commonly considered factors associated with the development of psoriasis, to explore the existence of variations in selected subgroups, and to evaluate the interaction between smoking and other documented risk factors.
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Results
The distribution of cases and controls according to age, sex, marital status, family history of psoriasis in first-degree relatives, alcohol consumption, BMI, and life events index is presented in Table I. Thirty-four percent of cases reported onset before age 30. No difference was observed between cases and controls for gender, marital status, or drinking habits. The risk of psoriasis was greater in those reporting a family history of psoriasis in first-degree relatives, the adjusted OR being 5.4 (95% confidence interval (CI), 3.77.8). The mean number of siblings was similar in cases and controls, 2.5 (standard error=0.12) in cases and 2.2 (standard error=0.09) in controls. The risk of psoriasis was directly related to BMI; the OR was 1.6 (95% CI, 1.12.1) for BMI 2629 corresponding to overweight subjects, and 1.9 (95% CI, 1.22.8) for BMI greater than 29, corresponding to obese people. An association also emerged between psoriasis and stressful life events in the year preceding the diagnosis. The life events index is presented according to the quartile distribution in the control group. The trend in risk was significant (
=10.76, p=0.001) but when males and females were considered separately, the trend in risk was evident for women only (data not presented).
Table I - Distribution of 560 cases of psoriasis and 690 controls and OR estimates according to age, sex, marital status, family history of psoriasis in firstdegree relatives, alcohol consumption, BMI, and life events index (Italy, 19881997).
Full table
Table II shows the distribution of cases and controls according to smoking habits for the whole sample and in gender strata. Overall, the OR for psoriasis was higher in former and current smokers. The data, however, suggested some gender differences. Male ex-smokers were at an increased risk of psoriasis; the adjusted OR for men being 2.1 (95% CI 1.33.5) whereas for women it was 1.2 (95% CI 0.62.2). For current smokers, the overall risk was 1.7 (95% CI 1.1 3.0). The risk was higher in women than men for whom the risk estimates seemed to correspond to no effect at all. When the type of cigarettes was considered categorized into four levels (very low, low, medium, and high tar concentration), no marked differences emerged; about 30% of current smokers usually smoked very low or low tar cigarettes, 63% medium tar cigarettes, and 4% high tar cigarettes, both in cases and controls (data not shown). Smoking consumption was also considered in terms of pack years, calculated by multiplying the number of packs of cigarettes smoked per day by the number of years the person had smoked. The median number of pack years was 11.8 in ex-smokers and 10.4 in current smokers (this difference was not significant). Cigars and pipe smoking accounted for only a minority of smoking habits in our population. Taking these into account did not materially change our risk estimates for smoking (data not shown).
Table II - Distribution of 550 cases of psoriasis and 690 controls according to gender and smoking habits (Italy, 19881997).
Full table
Table III considers the combined effect of smoking and, in turn, family history of psoriasis among first-degree relatives, alcohol consumption, BMI, and life events index. The risk
increased about 2-fold in smokers and drinkers as compared with non-smokers non-drinkers, and about 9-fold when smokers having a history of psoriasis in first-degree relatives were compared with non-smokers with no family history of psoriasis in first-degree relatives. The risk also increased in smokers with a higher BMI, and in smokers with a higher stressful life event index. The OR was around 3 for smokers with a BMI 30 and around 5 for smokers with a life event index 89 (30 and 89 being the approximate tertiles of the life event index in the control group). These results are in agreement with a multiplicative model for risk combination between smoking habits and the other risk factors analyzed.
Table III - OR estimates for psoriasis according to combined effect of smoking habits (never vs ever smokers) and, in turn, family history in first-degree relatives, alcohol consumption, BMI, life events index (Italy, 19881997).
Full table
Table IV presents OR estimates for smoking habits, BMI, and life events index according to the clinical variety of psoriasis. A particularly strong association was confirmed between smoking and pustular psoriasis, OR=5.3 (2.113.0).
Table IV - OR estimates for smoking habits, BMI, and stressful life events index in selected clinical varieties of psoriasis (Italy, 19881997).
Full table
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Discussion
This study confirms that smoking, BMI, and stressful life events are independently correlated with psoriasis, and that their risks combine according to a multiplicative model without evidence for statistical interaction. Our study highlights a relationship between smoking and psoriasis, showing some gender difference and documenting a strong association between smoking and pustular psoriasis.
Some limitations within our study design should be considered. Our cases were patients diagnosed for the first time in their lives as suffering from psoriasis with a history of skin manifestations no longer than 2 y. Our aim was to restrict the assessment to recently developed cases. In Italy, specialist consultation is offered by the National Health Service at the request of the primary care physician and it is usual practice to refer all but the most trivial dermatology cases. We took into account the first diagnosis of psoriasis without any reference to disease severity. It is possible that the risk factors we analyzed were correlated with disease severity rather than mere disease occurrence. Unfortunately, we are unable to assess this relationship in our study. We limited the entry criteria to subjects aged 16 y or older. As a consequence, our data cannot be generalized to psoriasis with an earlier onset where other factors may play an etiologic role. The choice of dermatological controls was mainly dictated by the need to control reasons leading to specialist consultation. We are aware that this may result in overmatching (i.e., choosing controls too similar to cases for the exposure variables). Our decision to use the date of the first diagnosis by a specialist as the index date may be questionable, the major problem being the inability to separate exposures to variables prior to clinical onset from exposure to variables after clinical onset. With the exception of psychological stress, however, all the factors we analyzed were long-lasting exposures usually preceding the onset of the disease by years. The retrospective nature of our study is a more general limitation because of the potential for recall and information bias. It is reassuring to note that the prevalence of smokers in our control group was similar to the estimates obtained in a study we recently conducted on a representative sample of the Italian adult population (Naldi et al, 2004). The study also documented an association between the prevalence of psoriasis and smoking, providing further epidemiological support to our findings (data on file). Recent Italian figures indicate that greater proportions of men than women have given up smoking. The association between previous smoker status and psoriasis in men may suggest that, as compared with the controls, a greater proportion of male psoriatics gave up smoking perhaps because of very early symptoms of the disease. If selective quitting is implicated, then the risk for current smoker status among men may be underestimated by our study. The statistical power of most subgroup and interaction analyses is inadequate. As a consequence, more weight should be given to our overall results rather than to any specific result in subgroups. Previous studies have provided some evidence for the association of psoriasis with smoking habits, BMI, and stressful life events. Interestingly, a number of diseases that are strongly linked with smoking in the general population, including among others, Crohn's disease (Lee et al, 1990), lung cancer, and tumors of the upper airways (Olsen et al, 1992;Boffetta et al, 2001) are also associated with psoriasis. Obesity has been linked with psoriasis in studies of prevalent cases (Vessey et al, 2000) and in a previous analysis of our dataset (Naldi et al, 1996). In spite of being frequently reported as a trigger, there is limited and conflicting evidence concerning the role of psychological stress in relation to the onset or exacerbation of psoriasis (Gupta et al, 1987,1989;Picardi et al, 2001,2003). Our study has confirmed these previously reported associations and provides evidence that stressful life events are linked to psoriasis at its first diagnosis. Several tentative biological explanations can be suggested for the associations we have documented. The following speculations are not meant to be exhaustive; they rather hint at possible connections and explanations that may be worthy of further research.
Smoke
The effect of smoking is the sum of complex actions of various substances, including nicotine and carbon monoxide, and is modulated by gender, genetic background, cigarette dose, and nicotine concentration. Psoriasis is a T cell immune-mediated disease and nicotine alters a wide range of immunological functions, including innate and adaptive immune responses (McAllister-Sistilli et al, 1998;Sopori, 2002). But contrasting results, according to the experimental model adopted, have been provided. Nicotine can modulate the functional capacity of dendritic cells (DC) (Aicher et al, 2003;Nouri-Shirazi and Guinet, 2003 ). Using human and murine DC, which are professional antigen-presenting cells (APC), it has been recently documented that nicotine can concentration-dependently induce DC expression of costimulatory molecules (i.e., CD86, CD40), MHC class II, and adhesion molecules (i.e., LFA-1, CD54). Moreover, nicotine induced a significant increase in the secretion of the proinflammatory T helper 1 cytokine interleukin-12 by human DC. These effects were abrogated by the nicotinic receptor antagonists -bungarotoxin and mecamylamine. The greater capacity of nicotinestimulated APC to induce T cell proliferation and cytokine secretion was also documented in mixed lymphocyte reaction and antigen-specific assays. Ovalbumin-stimulated T cells from DO10.11 mice bearing the specific transgenic T cell receptor were used (Aicher et al, 2003). Other experiments involving chronic exposure of mice and rats have showed that cigarette smoke affects T cell responsiveness, which may account for the decreased T cell proliferative and T-dependent antibody responses in humans and animals exposed (Kalra et al, 2000). In LEW rats, a decreased response to sheep red blood cells by antibody plaque-forming cells (AFC) was also observed after intracerebroventricular administration of relatively small concentrations of nicotine (28 g per day per kg body weight), which when given peripherally, did not affect the AFC response (Sopori et al, 1998). These results support the hypothesis that nicotine alters immune responses by directly interacting with T cells and human and/or murine DC, as well as indirectly through brainimmune interactions. In addition, nicotinic cholinergic receptors have been demonstrated on keratinocytes stimulating calcium influx and accelerating cell differentiation (Grando et al, 1996). Constant stimulation of these receptors may control keratinocyte adhesion and upward migration in the epidermis. As we have already mentioned, psoriasis has been associated with Crohn's disease and less consistently with ulcerative colitis (Yates et al, 1982;Lee et al, 1990;Najarian and Gottlieb, 2003). A large body of evidence indicates that smoking triggers Crohn's disease and influences disease progression (Cosnes et al, 2001,2004 ). As observed in psoriasis, these effects are modulated significantly by gender, with women being at a greater disadvantage than men. The possibility of a common susceptibility gene, i.e., CARD15, in Crohn's disease and psoriatic arthritis, was recently suggested (Rahman et al, 2003 ) but not confirmed (Giardina et al, 2004). Differing from Crohn's disease, former but not current smokers appear to be at increased risk for ulcerative colitis. It has been postulated that the withdrawal of the immunosuppressive effect of smoking triggers the disease onset in a genetically susceptible individual or simply unmasks its symptoms (Abraham et al, 2003). Such a hypothesis may be relevant to explain the association we have documented between former smoking status and psoriasis in men.
BMI
BMI is a complex variable that correlates fairly well with the degree of adiposity, and is affected by both genetic and environmental factors, e.g., caloric intake (Bjorntorp, 1997;Rosenbaum et al, 1997). BMI, in turn, appears to affect several biological variables including immunity (Tanaka et al, 1993,2001). It has been documented that circulatory levels of tumor necrosis factor (TNF)- , soluble TNFreceptors, and in vitro TNF- production are significantly increased in obese subjects as compared with non-obese subjects. In obese subjects, there is a significant positive correlation between serum levels of TNF- and waisthip ratio, serum levels of soluble TNF- receptor 1 and body weight, and soluble TNF- receptor 2 and BMI. The T cell responses and previously reduced T cell subsets increase significantly following weight reduction (Tanaka et al, 2001). It has been documented that fasting may improve at least temporarily inflammatory conditions including psoriasis (Lithell et al, 1983;Kragh-Kjeldsen et al, 1991). Recently, a link has been established between obesity and a proinflammatory state in the so-called metabolic syndrome (Grundy et al, 2004).
Stress
There is some evidence to suggest that psychological stress may modulate immune functions in humans and experimental animals, depending on the nature of the stressor and the immune variable under consideration (Miller et al, 1998). Interestingly, it has been documented that stressinduced anxiety is related to a T helper 1-like response (Maes et al, 1998). Based on experiments where a psychological stress was applied before immunization, it has been proposed that stress exerts an adjuvant effect on DC by promoting enhanced migration to lymph nodes and resulting in increased antigen-specific T cell responses. Such an effect appears to be modulated by release of norepinephrine by sympathetic nerve ends (Saint-Mezard et al, 2003).
Conclusions
Our data indicate that chronic exposure to selected environmental factors, i.e., smoking, and more acute triggers, i.e., psychological stress, may influence the development of psoriasis and affect its clinical expression. The impact of the factors we have analyzed on the causation of psoriasis is far from negligible from a public health point of view. In terms of population attributable risk (Bruzzi et al, 1985) tobacco smoking accounted for 26% of all the psoriasis cases, family history of psoriasis in first-degree relatives accounted for 22%, and BMI accounted for 16%. When the combined effect of tobacco and BMI was considered, it accounted for 48% of all the cases in this population and 42% in people without a family history of psoriasis. Similar considerations can also apply to stressful life events. The effect of environmental factors on the extension, distribution (e.g., acral lesions), clinical variety, and response to treatment of psoriasis should be further evaluated in prospective studies.
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Subjects and Methods
The general design of this study has been previously described (Naldi et al, 1992,1996,1999). Briefly, between January 1988 and December 1997, trained interviewers identified and interviewed cases and controls using a standard questionnaire. The study was conducted in three separate periods (19881991, 19921993, 19941997). It was our aim to recruit about 200 cases, during each study period, with a similar number of controls. Analyses were conducted at the end of each study period and more focused hypotheses were formulated for the next study phase. These hypotheses involved amending the questionnaire and adding in new items (in particular, life events index and passive smoking were added in 1992). The study involved a total of 20 dermatologic centers from different Italian regions (14 centers from northern Italy). The results of the three phases of the study were comparable, and no significant differences between participating centers were observed. The study has been approved by the medical ethical committee of the Bergamo General Hospital. The study was conducted according to the Declaration of Helsinki Principles. Participants gave their written informed consent. Only subjects aged 16 y or older were eligible. Entry criteria for cases were as follows: a first ever diagnosis of psoriasis made by a dermatologist and a history of skin manifestations up to 2 y after the reported disease onset. The onset was considered as the date an individual first became aware of the clinical manifestations attributable to psoriasis. The definition of onset was established by a thorough enquiry into the timing of relevant signs and symptoms. All eligible patients who were seen consecutively during the study period were invited to participate. A total of 560 cases (318 males, 242 females, median age 38 y) and 690 controls (345 males, 345 females, median age 36 y) were included. The psoriasis cases were classified as: psoriasis vulgaris (415, 74.1%), guttate (98, 17.5%), pustular, i.e., plaque psoriasis associated with pustular lesions and generalized pustular psoriasis (32, 5.7%), and other varieties including flexural and erythrodermic psoriasis (15, 2.7%). Controls were patients attending the same outpatient centers as the cases, with a first diagnosis of a dermatological condition other than psoriasis. Diagnoses in the control group included eczema (25%), skin cancer (16%), urticaria (14%), skin infections (13%), pityriasis rosea (10%), acne (8%), reported changes in melanocytic nevi (8%), rosacea (2%), angiomatous lesions (2%), and a variety of other skin diseases (2%). Less than 3% of cases and controls refused to be interviewed. Information was collected on sociodemographic factors, smoking habits (daily consumption of cigarettes, cigar, and pipe), alcohol, coffee, and tea consumption, consumption of selected dietary factors, family history of psoriasis in first-degree relatives (i.e., parents and siblings), history of stressful life events, and thorough medical history. Anthropometric measures including height and weight were also obtained. A period of abstinence of 1 y before the date of diagnosis was required for patients to be classified as ex-smokers or ex-drinkers. An Italian version of the Holmes and Rahe Social Readjustment Rating Scale was used to assess stressful life events during the year before the diagnosis. The scale included 47 items, each providing a score proportional to the associated stress, e.g., partner death (score 100), pregnancy (score 40), job troubles (score 23), small law violations (score 11, the smallest score in the scale). Total sum scores on the scale were used for the analysis.
Data analysis
For each factor, we calculated the OR of psoriasis as estimates of relative risks and its corresponding 95% CI. To account simultaneously for the effects of age, sex, calendar year, and other selected covariates, unconditional multiple logistic regression with maximum likelihood fitting was used (Breslow and Day, 1980). Attributable risks were calculated by means of the method described byBruzzi et al (1985).
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Acknowledgments
The study was partly supported by grants from the following drug companies: Janssen-Cilag, Roche, Schering, Boehringer Ingelheim, Glaxo-Wellcome, Novartis. The contribution of the Italian League against Cancer is also gratefully acknowledged. We wish to thank Leigh Martin for editorial assistance and the dermatologists in the participating centers for making this study possible. We are grateful to Lucienne Chatenoud for her helpful suggestions.
o
Psychiatry Investig. 2011 Dec;8(4):327-33. doi: 10.4306/pi.2011.8.4.327. Epub 2011 Nov 3.
Alexithymia and acne vulgaris: a case control study.

Sunay D, Baykir M, Ate G, Ekiolu M.
Source
Department of Dermatology, Ministry of Health, Ankara Training and Research Hospital, Ankara, Turkey.
Abstract
OBJECTIVE:
To assess relationship between alexithymia and acne vulgaris in young people.
METHODS:
A hundred and eleven subjects between 15 and 25 years of age referred to out-patient clinic of dermatology with acne and 78 subjects applied to family physician for complaints other than acne were included in patient and control groups of the study, respectively. A questionnaire to determine demographic characteristics, an acne classification to determine severity of acne and Toronto Alexithymic Scale (TAS) to assess alexithymia were used.
RESULTS:
The mean scores of TAS were 52.710.8 and 51.710.7 in patient and control groups, respectively. Alexitymia was determined in 23.4% of the subjects in acne group and in 24.4% of control group. No significant differences were found between groups in terms of alexithymia, intermediate alexitymia and three-factors of TAS.
CONCLUSION:
Alexithymia does not appear to be related to acne vulgaris.

KEYWORDS:
Acne vulgaris, Alexithymia, Young people

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Acta Derm Venereol. 2009;89(4):364-8. doi: 10.2340/00015555-0669.

Relevance of psychosomatic factors in psoriasis: a case-control study.

Materials and methods

Clinical and psychological characteristics of the sample

Psoriasis severity and psychosocial variables

Social support and adaptation to the diseasecorrelational analysis

Social support and adaptation to the diseaseregression analysis

Social support and adaptation to the diseasecluster analysis

nal CME Activities

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Psychiatric Issues in Dermatology, Part 1: Atopic Dermatitis and Psoriasis

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Primary Psychiatry. 2008;15(7):35-38

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Atopic Dermatitis and Stress

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Psychosocial Morbidity in Atopic Dermatitis

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Psychiatric and Psychological Treatments for Atopic Dermatitis

Determ Malinge Disabili Evaluat

Psoriasis and Lithium

Psychosocial Morbidity in Psoriasis

Psoriasis and Suicide

Psoriasis and Stress

Psychiatric and Psychological Treatments for Psoriasis

Article first published online: 29 JUL 2006 DOI: 10.1111/j.1365-2133.1994.tb02900.x Issue

British Journal of Dermatology

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Article first published online: 22 JUN 2005

DOI: 10.1111/j.1365-2133.2005.06565.x Issue

British Journal of Dermatology

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Dermatology 2008;216:8792 (DOI:10.1159/000111504)

New Hypotheses in the Genetics of Psoriasis and Other Complex Diseases

T Henseler , E Christophers Abstract

PII: S0190-9622(85)70188-0 1985 Mosby, Inc. All rights reserved.

The Psychosocial Burden of Psoriasis

Dr Alexa B. Kimball, Christine Jacobson, Stefan Weiss, Mary G. Vreeland, Ying Wu

Ann Rheum Dis 2005;64:ii18-ii23 doi:10.1136/ard.2004.033217

Psoriasis: epidemiology, clinical features, and quality of life

Life events involvement in psoriasis onset/recurrence

International Journal of Dermatology

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Perceived stress, stress attributions and psychological distress in psoriasis

Catherine J. O'Leary , Daniel Creamer , Elisabeth Higgins , John Weinman

Received 7 October 2002; accepted 5 March 2004.

Abstract Full Text PDF References

Perceived stress, stress attributions and psychological distress in psoriasis

Catherine J. O'Leary , Daniel Creamer , Elisabeth Higgins , John Weinman

Received 7 October 2002; accepted 5 March 2004.

Abstract Full Text PDF References