Psoriasis is a chronic, immune-mediated skin disorder affecting millions of people worldwide. The most common form of psoriasis, plaque psoriasis, affects approximately 80% of patients. Overall, 25-30% of patients have moderate-to-severe psoriasis, and 50% develop nail pitting. Like many other dermatological disorders, psoriasis is associated with a number of psychological and social effects on the lives of patients.
Psoriasis, like any long-standing disorder, can inevitably leave a debilitating effect on a person's psychology. The relationship between psoriasis and psychosocial stress is complex. It can result in sufferers being socially withdrawn owing to the disfigurement and the associated stigma, resulting in even greater stress.[59,60] A study revealed that 39% of patients recalled a considerable stressful event, such as family tensions, death or hospitalization of loved ones, accidents, emergencies and sexual assault, within 1 month before the first episode of psoriasis. In patients with otherwise stable psoriasis, the stress can also result in flare-ups. Patients with greater psoriasis-related stress have been found to have more cosmetically disfiguring psoriasis or on 'emotionally charged' regions such as face, hands and genital regions.
Depression and suicidal thoughts are not uncommon in psoriasis patients and it is noticed that approximately 10% of psoriatic patients' suffer from suicidal ideation. The cosmetic disfigurement and the impact of psoriasis on patients' QoL are important cofactors for depression and suicide.
Patients suffer from feelings of stigmatization, social rejection, shame, embarrassment and a lack of confidence resulting in significant levels of the disruption of their day-to-day life and making them socially withdrawn. Many of them prefer to remain confined to their homes and may even develop antisocial behavior.
Other aspects of social functioning that could be affected are the patient's participation and interaction at school or in the workplace, resulting in either not working at all or losing days of work. Leisure activities could also be affected; 72% of patients were found to avoid swimming, 60% avoided sunbathing, 40% avoided playing sports and communal facilities were avoided by 64%. Psoriasis was also shown to affect people's choice of clothing, which could be avoiding short-sleeved summer clothes or shorts, and dark-colored clothes because of the fear of higher visibility of scales.
Psoriasis can have a devastating impact on patients' sexual lives resulting in the inhibition of sexual activity especially in those with plaques in and around the genital area compared with those without genital lesions.
Recent literature has shown that patients with psoriasis are also more at risk of developing a number of comorbidities in the form of metabolic and cardiovascular disorders, possibly because of the production of increased levels of proinflammatory cytokines.[66,67] Psoriasis patients were found to be significantly more likely to develop hypertension, diabetes, hypercholesterolemia and obesity, compared with the control population.[68,69] They were also found to suffer more from sleep problems, depression, gastroesophageal reflux and chronic obstructive pulmonary diseases. Most of these comorbidities are associated with severe psoriasis and manifest clinically, often years after the onset of psoriasis.
The impact of psoriasis is not limited to the patients but can also extend to their families. The time taken for treatment, disruption of the family's social life, affect on daily activities, extra housework, reluctance to leave home and avoidance of public places for the sake of the patients are some of the aspects of the family life affected by patients' psoriasis.[65,70]
Drinking & Smoking
Psoriasis patients drink more alcohol than controls. Alcohol is not only a risk factor for exacerbating the psoriasis but the stress of psoriasis could lead to a relief drinking, which, ultimately, could lead to a decreased compliance with treatment. Alcohol consumption of more than 80 g/day could be a problem and may have an adverse effect on the treatment outcome in patients with psoriasis. Therefore, psoriasis patients should receive education about alcohol abuse and its effect on treatment. Similar to alcohol, smoking is commoner among psoriatic patients than controls. Smoking has been shown to be a risk factor for the development of psoriasis and smoking more than ten cigarettes daily can severely affect the distal parts of the upper and lower limbs, such as palms and soles.
Psoriasis can have a wide range of direct and indirect financial implications. Direct costs for the patient includes physician visits, day treatment, hospitalization and cost of topical or systemic treatment, for example. The indirect cost to the society may result from the number of days taken off by patients, time lost from work, due to, for example, hospital appointments, or even unemployment due to psoriasis. In one large study, 60% of study participants blamed psoriasis in the preceding years for their time lost from work and 40% expressed that they did not work owing to psoriasis. The direct annual cost of caring for psoriasis patients has increased considerably over the years. In the USA, in 1984 it was estimated that the cost of the outpatient care of around 2.3 million sufferers at the time was US$1.5 billion per year. On average, US$650 per patient per year were spent on laboratory tests, medication costs and physician visits. In Europe, the average cost of psoriasis treatment was estimated in an Italian study as €905 per patient per year. Although the relative costs associated with psoriasis of different degrees of severity is still not documented, one study suggests that the more severe the psoriasis, the higher the cost of care in terms of the cost of treatment, time required for treatment and time lost from work.
Expert Rev Pharmacoeconomics Outcomes Res. 2009;9(3):271-283. © 2009 Expert Reviews Ltd.
Cite this: Burden of Skin Diseases - Medscape - Jun 01, 2009.