Dónal G. Fortune

Patients with psoriasis and their compliance with medication

BACKGROUND Poor compliance with treatment advice in chronic conditions, such as psoriasis, represents a major challenge to health care professionals. Previous research suggests that the rate of noncompliance in chronic conditions may be as high as 40%. OBJECTIVE This study was designed to examine self-reported compliance in patients with psoriasis. METHODS We undertook an anonymous postal survey sent to consecutive patients with psoriasis attending a tertiary psoriasis specialty clinic. RESULTS Thirty-nine percent of participants reported that they did not comply with the treatment regimen recommended. The noncompliant group had a higher self-rated severity of psoriasis (t = -2.16, P =. 03), were younger (t = 3.28, P =.001), and had a younger age at onset (t = 2.35, P =.02) than those who were compliant. The noncompliant group reported that psoriasis had a greater impact on daily life (t = -2.23, P =.028), but general well-being was not significantly different from those who complied (t =.47, P = not significant). CONCLUSION Patients who reported intentional noncompliance with treatment advice were more likely to believe that both psoriasis and its treatment interfered with their quality of life but not overall well-being. The impact of treatment on daily life highlights the importance of joint decision making in planning treatment.

The contribution of perceptions of stigmatisation to disability in patients with psoriasis

OBJECTIVE The aim of the present study was to assess the significance of general and psoriasis specific psychological variables in patients with psoriasis and to examine the relative importance of disease status and these psychological variables in predicting psoriasis-related disability. METHOD A total of 115 patients with psoriasis underwent clinical assessment and completed a number of psychological and psoriasis specific questionnaires. RESULTS High levels of self-reported distress were identified with 43% and 10% of patients scoring as probable cases on the Hospital Anxiety and Depression Scale (HADS) subscales of anxiety (mean 9.3+/-4.9) and depression (mean 4.8+/-3.7), respectively. Multiple regression analysis indicated that clinical severity of psoriasis and anatomical area of involvement had no impact on psychological distress and disability. Perceptions of stigmatisation were significantly related to both psychological distress and degree of disability (Ps<.001) and accounted for a significant amount of the variance in disability over and above general psychological distress (F change=11.03; P<.001). CONCLUSION Psychological factors were much stronger determinants of disability in patients with psoriasis than disease severity, location or duration. This has important implications in relation to the clinical management of psoriasis.

A cognitive‐behavioural symptom management programme as an adjunct in psoriasis therapy

Summary Background Patients with psoriasis may experience significant psychological and social disabilities. Stress or distress are proposed aggravators of the disease process in psoriasis. Preliminary studies to date have suggested that adjunctive psychological therapies may be effective in the clinical management of psoriasis.

The Salford Psoriasis Index: an holistic measure of psoriasis severity

We have developed, tested and validated a new scoring system for psoriasis: the Salford Psoriasis Index (SPI). The SPI incorporates the current clinical extent of psoriasis based on the Psoriasis Area and Severity Index (PASI), a score indicating psychosocial disability, and past severity based on treatment history. The resultant three‐figure SPI (signs, psychosocial disability, interventions) is a similar paradigm to the TNM (tumour, nodes, metastasis) classification used for cancer staging. The first figure transforms the PASI into a number from 0 to 10 reflecting extent of psoriasis. The second assesses the psychosocial impact of psoriasis on each patient using a 0–10 visual analogue scale. The third figure reflects historical severity of disease as judged by the need for systemic treatment, admission to hospital and number of episodes of erythroderma.

Adherence to treatment in patients with psoriasis

Non‐adherence to medication is a chronic problem that impacts on healthcare professionals and patients alike. In psoriasis, a condition that presents patients with frequent and disabling physical, psychological and social effects, studies consistently suggest that up to 40% of patients do not use their medication as directed. Thus it is probable that poor adherence contaminates the clinical picture of response effectiveness in everyday practice. This educational paper reviews research that investigates adherence to medication in patients with psoriasis. It provides an overview of contributing factors and mediating variables. It is proposed that three specific facets appear to optimize patient adherence: an effective doctor–patient relationship; optimism with the treatment prescribed; and a limited ‘nuisance’ value of treatment in terms of side‐effects and hassle of use. Various strategies to address adherence are suggested and it is argued that in order to enhance our understanding of adherence in patients with psoriasis, there needs to be an increasing focus on patients’ beliefs about their condition and its management.

Alcohol consumption and psychological distress in patients with psoriasis

Background  Psoriasis has been associated with excessive alcohol consumption and psychological distress.

Detection of psychological distress in patients with psoriasis: low consensus between dermatologist and patient.

Background  Researchers have indicated that 30–40% of patients with psoriasis suffer significant psychological distress. For the appropriate clinical management of the patient with psoriasis it is important that dermatologists are able to recognize this distress.

RESPONSE OF THE HYPOTHALAMIC-PITUITARY-ADRENAL AXIS TO PSYCHOLOGICAL STRESS IN PATIENTS WITH PSORIASIS

Background  Psoriasis may, in some patients, be triggered and/or exacerbated by stress.

Patients' strategies for coping with psoriasis

Summary There is a paucity of research on the types of strategies that patients with psoriasis use to cope with the impact of their condition. By contrast there are a number of studies assessing coping by patients with nondermatological disease. The purpose of the present study was to examine strategies for coping in patients with psoriasis and investigate whether they differ as compared with normal controls and patients with other major medical diseases. Two hundred and fifty patients with a definite dermatologist‐confirmed diagnosis of psoriasis participated in this cross‐sectional study. Patients were assessed by psoriasis area severity index and all patients completed the COPE questionnaire and psoriasis disability index. Sixty healthy, control participants completed the COPE questionnaire for comparison purposes. Mean COPE scores from patients with psoriasis were also compared with published COPE scores from other medical diseases. The coping strategies most frequently used by patients with psoriasis were acceptance, planning, active coping and positive reinterpretation. The least frequently used were alcohol and nonprescription drugs, religion, and denial of their condition. Despite reporting greater disability, patients with severe psoriasis did not significantly differ from those with mild/moderate disease in their use of particular forms of coping strategies. Patients with psoriasis as a whole tended to use significantly less active coping strategies, planning, positive reinterpretation and humour when compared with normal controls. There was marked similarity in the frequency of use of particular coping strategies between patients with psoriasis and patients with other medical conditions. Similar types of coping strategies are utilized by patients regardless of whether their illness is visible (psoriasis) invisible (chronic fatigue syndrome, atrial fibrillation), has significant physical impairment (spinal cord injury), or is life‐threatening (cancer, and myocardial infarction). It appears that illness brings with it a generic form of coping that may require shaping to fit the individual demands of diseases such as psoriasis.

Pain drawings in the assessment of nerve root compression: a comparative study with lumbar spine magnetic resonance imaging.

Study Design. Prospective comparative study of pain drawings with findings on lumbar spine magnetic resonance imaging. Objectives. To assess the ability of the pain drawing to predict the presence of nerve root compression. Summary of Background Data. Most research work has concentrated on the ability of the pain drawing to act as a screening method for psychological distress with less work directed at the influence the anatomic abnormality has on the pain drawing. Methods. One hundred thirty‐four consecutive out‐patients attending for lumbar magnetic resonance imaging in the investigation of back and leg pain completed pain drawings and psychological testing immediately before the examination. The pain drawing was analyzed by previously reported criteria, and the magnetic resonance imaging was assessed independently for the presence of nerve compression by three radiologists. Multivariate stepwise discriminant analysis was used to identify patients with nerve compression on the basis of their pain drawing. Results. Nerve compression was predicted by numbness in the anterolateral aspect of the foot. There was considerable overlap in the appearances of the pain drawings between patients with and without nerve compression, and the pain drawing correctly classified only 58% of patients with nerve compression. Conclusions. The pain drawing is not a good predictor of nerve compression on magnetic resonance imaging in a group of patients investigated for back and leg pain. It should be interpreted with caution and in light of the full clinical picture.