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Quality of life


symptoms and feelings, daily activities, leisure, work and school, personal relationships and treatment. It is a ten-question survey that yields a score ranging from 0 to 30, with low scores indicating that the disease has less impact on a patient’s daily activities.15 There is a significant correlation between the clearance of skin lesions and the improvement in QoL, measured as reduction in DLQI scores. Biologics have emerged as an innovative treatment modality for moderate to severe chronic plaque psoriasis and they have been shown to be effective in improving QoL, depression and fatigue.16


In general, a


treatment is considered effective when there is significant reduction in the DLQI that reaches an absolute score <5. Also, a DLQI of 0 or 1 indicates no impact on QoL due to the skin problems.


Cumulative Life Course Impairment


10


Patients with poorly managed psoriasis may follow a different or diminished life course compared with what they might have expected had they not had the condition.


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The CLCL is the result from the interaction between impairing factors (comorbidities, psychological disorders) and protective factors (coping strategies, support from their environment, family or social and personality styles). The different balances that can be generated by the interaction of these factors explain the differences in the impact of psoriasis in patients with cutaneous involvement of similar intensity, that is, the inter- individual differences that are observed in clinical practice. Economically, patients with psoriasis can have difficulties gaining and retaining paid employment or working to their full potential, which may limit their lifetime earning potential and can result in societal cost associated with productivity loss.18


It has become increasingly relevant that any measurement of QoL should not only capture a point-in-time of the patient's life, but also cumulative disability throughout the life course of the disease. Indeed, moderate to severe psoriasis could negatively interfere with the patient’s ability to maximise his/her life potential. This concept is the so-called ‘Cumulative Life Course Impairment’ (CLCI), which refers to the progressive disability that the psoriatic patient accumulates over the course of a lifetime.17


The assessment of CLCI allows a better understanding of the real impact that psoriasis has on a patient's QoL, and therefore allows better clinical management (therapeutic and psychological) of the patient.


Conclusions


There is increasing evidence that psoriasis affects several facets of QoL and that impairment could be cumulative. CLCI is difficult to assess and quantify; however, longitudinal studies to this end are ongoing. Future research should focus on establishing key components of CLCI, determining the mechanisms of impairment and assessing factors that put patients at increased risk of developing CLCI. This concept may lead to a better understanding of the overall impact of psoriasis, help identify more vulnerable patients, and facilitate more appropriate treatment decisions or earlier referrals. l


References 1. Nestle FO, Kaplan DH, Barker J. Psoriasis. N Engl J Med 2009;361:496–509.


2. Lande R et al. The antimicrobial peptide LL37 is a T-cell autoantigen in psoriasis. Nat Commun 2014;5:5621.


3. Tsoi LC et al. Enhanced meta-analysis and replication studies identify five new psoriasis susceptibility loci. Nat Commun 2015;6:7001.


4. Coates LC et al. Systematic review of treatments for psoriatic arthritis: 2014 update for the GRAPPA. J Rheumatol 2014;41:2273–6.


5. Gisondi P et al. Management of moderate to severe psoriasis in patients with metabolic comorbidities. Front Med (Lausanne) 2015;2:1.


6. Schmitt J, Küster D. Correlation between Dermatology Life Quality Index (DLQI) scores and Work Limitations Questionnaire (WLQ) allows the


calculation of percent work productivity loss in patients with psoriasis. Arch Dermatol Res 2015;307(5):451–3.


7. Sampogna F et al. Measuring quality of life of patients with different clinical types of psoriasis using the SF-36. Br J Dermatol 2006;154:844–9.


8. Rapp SR et al. Psoriasis causes as much disability as other major medical diseases. J Am Acad Dermatol 1999;41:401–7.


9. Augustin M, Radtke MA. Quality of life in psoriasis patients. Expert Rev Pharmacoecon Outcomes Res 2014;14:559–68.


10. Balta I et al. General psychiatric symptoms, quality of sleep, and coping strategies in patients with psoriasis vulgaris. Int J Dermatol. 2015;May 6 [Epub ahead of print].


11. Böhm D et al. Perceived relationships between severity of psoriasis symptoms, gender, stigmatization and quality of life. J Eur Acad Dermatol Venereol 2013;27:220–6.


12. Smith CH et al. British Association of Dermatologists' guidelines for biologic interventions for psoriasis 2009. Br J Dermatol 2009;161:987–1019.


13. Pathirana D et al. European S3-guidelines on the systemic treatment of psoriasis vulgaris. J Eur Acad Dermatol Venereol 2009;23 Suppl 2:1–70.


14. Nijsten T. Dermatology life quality index: time to move forward. J Invest Dermatol 2012;132:11–13.


15. Finlay AY, Khan GK. Dermatology Life Quality Index (DLQI)—a simple practical measure for routine clinical use. Clin Exp Dermatol 1994;19:210–16.


16. Gisondi P, Girolomoni G. Impact of TNF-α antagonists on the quality of life in selected skin diseases. G Ital Dermatol Venereol 2013;148:243–8.


17. Kimball AB et al. Psoriasis: is the impairment to a patient's life cumulative? J Eur Acad Dermatol Venereol 2010;24:989–1004.


18. Horn EJ et al. Association of patient-reported psoriasis severity with income and employment. J Am Acad Dermatol 2007;57:963–71.


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