Psoriasis impact goes more than skin deep

Many doctors, including dermatologists, would rather not address patients’ feelings about psoriasis. It’s part of how dermatologists protect themselves from bearing the burdens of patients’ woes, according to Richard Fried, M.D., Ph.D., a dermatologist and clinical psychologist in Yardley, Pennsylvania.

RELATED: Integrating primary care and mental health key to improving patient care

“When we first introduce psychological burden or psychological impact of psoriasis, often eyes start to roll. ‘Blah, blah, blah, I’ve heard it a hundred times: Psoriasis sucks. So does acne. So does eczema,’” Dr. Fried says. “(The reaction represents dermatologists’) self-protective mechanism. It tries to protect us from getting damaged, drained, hurt, to the point where we’re too exhausted or too emotionally wounded to do our jobs.”

It’s a lot easier, he says, to assess a patient’s physical condition and write a script. One might give a reassuring nod and say, “That’s psoriasis by the way. It’s not contagious. Don’t worry about it.’

“That’s very different than hearing and feeling their stories,” Dr. Fried says.

When it comes to treating and managing psoriasis patients, ignoring the psychosocial aspect is akin to ignoring the elephant in the room. Researchers have found the psychosocial effects of psoriasis can equal those experienced with heart failure or cancer. And that’s a big problem, given psoriasis is the common autoimmune disease in the United States. As many as 7.5 million Americans have the condition, according to the National Psoriasis Foundation (NPF).

“Concretely, these are people who are at higher risk for and higher occurrence of suicide. These are people who suffer with much greater levels of depression, anxiety, social isolation, unemployment, marital impairment, sexual impairment, disorders obviously contributing to or from very impaired self-image,” Dr. Fried says. “It’s important that, as dermatologists, we are reminded of how big a deal this is. And it’s important that we … have in the forefront of our clinical decision making ideas and plans for what we can do to decrease the burden in a given individual.”

Next: Extent of psoriasis' impact

Read more:

Psychosocial impact of psoriasis: The statistics

Psoriasis from the patient's perspective

Psoriasis stress response in vitro

Psoriasis and comorbidities a worldwide issue

Anecdotal, scientific evidence

Psoriasis affects the way people perceive themselves. It affects how people are perceived by others. And it affects how people think other people perceive them, according to Steven R. Feldman, M.D., Ph.D., professor of dermatology at Wake Forest University School of Medicine, Winston-Salem, N.C.

Colleagues, friends and friends would see the lesions or flakes from his head and say, “Ew, what’s your problem?” Or, “Ew, what do you have?” - Brian Lafoy, 44, of Plano, Texas, diagnosed with psoriasis in his early 20s, tells his story of how psoriasis impacted his life

Having psoriasis affects self-esteem, impacts emotion and diminishes quality of life, according to a survey of 4,725 psoriasis sufferers conducted by the NPF. Among the findings of the telephone and Internet surveys conducted from 2004 through 2009:

• More than 70 percent of respondents reported feeling self-conscious about their psoriasis;

• Forty-one percent said they dress to conceal the lesions;

• Fifty-six percent said psoriasis interferes with their capacity to enjoy life; and

• 63 percent revealed the skin disease impacts their overall emotional well-being.

• Nearly 60 percent said psoriasis was a large problem in their everyday lives.

Women surveyed report suffering psychosocially more than men. For example, 71 percent of women said they were embarrassed and 73 percent said they felt helpless because of their psoriasis. That was compared to 65 percent of men who felt embarrassed and 69 percent of men who felt hopeless because of it. Women, according to the NPF, are particularly sensitive about how psoriasis affects their appearance.

The NPF reports that, like women, minorities with psoriasis seem to suffer more psychosocially. This could be explained, in part, because of a greater prevalence of very severe disease in the minority respondent group. For example, nearly a quarter of African-American respondents had very severe psoriasis. Among those findings: 72 percent of minority respondents said psoriasis interfered with their capacity to enjoy life, compared with 54 percent of Caucasians.

In general, younger people seem to be more affected than their older counterparts with psoriasis. Among the striking findings: 84 percent of those ages 20 to 39 said they felt angry or frustrated by psoriasis, versus 69 percent of respondents older than 40, according to the NPF.

Next: Psychiatric comorbidities associated with psoriasis

Enter depression, other illnesses

Psychiatric comorbidities associated with psoriasis often go undetected and untreated, and psoriasis is more highly associated with psychiatric illness than other dermatologic conditions, according to a review by Rieder and Tausk (Rieder E, Tausk, F. Int J Dermatol. 2012;51(1):12-26).

Dr. Feldman and others have looked at rates of suicide and depression in patients with psoriasis and found both to be higher than among controls.

“In our survey of patients with psoriasis, 10 percent had thought about committing suicide due to their psoriasis at some point in their lives,” Dr. Feldman says.

In a large United Kingdom study published August 2010 in Archives of Dermatology, researchers found that compared to controls, psoriasis patients were 39 percent more likely to be clinically diagnosed with depression, were at 31 percent higher risk for anxiety and at 44 percent increased risk of suicidality (Chosidow O, Dellavalle RP, Do D, et al. Arch Dermatol. 2010;146(8).

The psychosocial distress people feel as the result of psoriasis is not necessarily associated with how severe the disease is. Harvard researchers published a review in the American Journal of Clinical Dermatology suggesting “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” (Kimball AB, Jacobson C, Weiss S, et al. Am J Clin Dermatol. 2005;6(6):383-392).

The psychosocial burden of psoriasis has far-reaching effects. One is economic impact. The NPF found that of the 40 percent of respondents who were not working at the time of the survey, more than a quarter said their lack of employment was due wholly or in part to their psoriasis and/or psoriatic arthritis. Researchers have found more than 17 percent of patients, ages 18 to 54, report psychological effects in the workplace due to their disease (Krueger G, Koo J, Lebwohl M, et al. Arch Dermatol. 2001;137(3):280-284).

Italian researchers reported in August 2013 that 55 percent of the 787 psoriasis patients in their study had limited expectations of career progression. About 60 percent of patients revealed psoriasis on their hands or feet caused work limitations. About a quarter reported it caused them to quit their jobs (Ayala F, Sampogna F, Romano GV, et al. J Eur Acad Dermatol Venereol. 21 Aug 2013 [Epub ahead of print]).

Next: Need for research

Emerging research

Experts agree that more research needs to be done on the psychosocial impacts of psoriasis and how to better manage patients. Researchers are making headway, however, in causes and potential treatments.

RELATED: Tips for addressing psychosocial needs

Francisco Tausk, M.D., professor of dermatology and psychiatry, University of Rochester, New York, and former president of the Association of Psycho-neuro-cutaneous Medicine of North America, and colleagues presented a recent mouse study looking at the effect of stress on psoriasis. His research, Dr. Tausk says, supports the idea that not all patients’ psoriasis gets worse with stress. The subgroup of patients that suffer post-stress flairs are most likely people who respond to stress with lower cortisol amounts (Richards HL, Ray DW, Kirby B, et al. Br J Dermatol. 2005;153(6):1114-1120).

Dermatologists might use this information in practice, he says, by understanding which patients would likely benefit most from stress reduction interventions.

Dr. Tausk also recently finished a study on the effects of mindfulness-based stress reduction on psoriasis. While the results of this study had not yet been analyzed, the new study was based on one done years ago by John Kabat-Zinn, Ph.D. (Kabat-Zinn J, Wheeler E, Light T, et al. Psychosom Med. 1998;60(5):625-632).

Dr. Kabat-Zinn looked at two psoriasis patient groups. One group received phototherapy only; the other, phototherapy and mindfulness meditation-based stress reduction intervention guided by audiotaped instructions during light treatments. The mindfulness meditation group cleared in half the time, according to Dr. Tausk.

“It shows that a very simple intervention can not only help the patients emotionally and psychologically but also help their skin disease,” Dr. Tausk says.

Future research might have more emphasis on mental health aspects of psoriasis. The NPF is calling on the National Institutes of Health (NIH) to get more involvement with the National Institutes of Mental Health (NIMH) because it is believed that psoriasis studies and treatment should routinely have input from the NIMH, Dr. Fried says.

“This is going to very high levels at this point with the recognition that it is leaving out an essential part of the equation not to have mental and emotional impact assessment for psoriasis patients,” he says.

Next:  The dermatologist's role

The dermatologist’s role

The impact of psoriasis co-morbidities on quality of life is an issue that is not commonly addressed by primary care physicians and subspecialists during regular visits. This omission represents a crucial gap in knowledge, creating a barrier to the effective treatment and well-being of these patients, Dr. Tausk says.

In a review published in 2013 in Dermatology and Therapy, researchers reported, “Psoriasis has a profound impact on mental health and well-being, which is under-recognized by clinicians.”

The U.K. researchers conducting the review wrote in the discussion that despite high levels of psychological distress among psoriasis patients, only 4 percent of dermatology unites in the U.K. provide dedicated counseling services (Moon HS, Mizara A, McBride SR. Dermatol Ther (Heidelb). 2013;3(2):117-130).

Obviously, the dermatologist’s role is to clear the lesions, Dr. Feldman says. But that’s not the first step in that patient’s care.

Step one with psoriasis patients is not to understand whether they have localized or generalized psoriasis. And step one is not to determine whether they need referral to a rheumatologist, according to Dr. Feldman.

“Step one in a psoriasis patient is to address the psychosocial needs of the patient,” he says. “I think dermatologists, as part of the treatment, should be expected and should hold themselves (responsible) for addressing those psychosocial issues.”

Next: Strategies for screening

But how?

Dermatologists can help patients address psychosocial needs simply by recommending they join the NPF. Dr. Feldman suggests all his patients get involved. The foundation offers credible information, support and comfort in knowing they’re not alone, he says.

Simple and quick strategies can help a dermatologist determine the extent to which a psoriasis patient is psychosocially affected by the skin disease.

Dr. Feldman says he screens his psoriasis patients for depression at every visit. He assesses their mood, in part, by watching their behavior. Lack of eye contact and paucity of movement are clues they might be depressed.

“If you get the sense they’re depressed, you can quickly ask them a screening question or two,” Dr. Feldman says.

He says his favorite questions (because they’re not very confrontational) are asking patients if they’ve had trouble sleeping and about their energy level. If those issues are problems, he’ll follow up with the more pointed questions, asking if patients think they’re depressed or if they feel suicidal.

“If you identify signs of depression, then you need to get them to their primary care doctor for treatment, and, if it’s severe, perhaps psychiatry,” Dr. Feldman says.

RELATED: Integrating primary care and mental health key to improving patient care

The dermatologist’s treatment plan should include getting the disease under better control, giving the person affected a sense of enhanced control and offering more information and opportunity for them to address some of the psychologic or psychiatric morbidities, according to Dr. Fried. In addition to looking into the NPF, dermatologists might recommend support groups or that patients engage in stress management modalities shown to make traditional therapies work better, such as progressive muscle relaxation, guided imagery, mindfulness meditation, self-hypnosis, yoga and tai chi, he says.

Dermatologists might also refer patients to psychologists, social workers or psychiatrists, according to Dr. Fried.

“There are many studies that show that cognitive behavioral psychotherapy has very substantial benefits in terms of making people get better much more quickly, with less treatment. Even antidepressive medications play a significant role,” he says. “There are fewer controlled studies using antidepressant medications but there is no question that they can be extremely beneficial.”

Rather than looking at probing into potential psychosocial issues and making referrals as more responsibilities on doctors’ shoulders, dermatologists should look at the practice as empowering themselves and their patients, Dr. Fried says.

“If we don’t feel empowered, in control and like we have something to offer in a given arena, we’re going to run from it,” Dr. Fried says. “My position has always been (as a psycho-dermatologist) that dealing with feelings does not necessarily have to be a time-consuming endeavor. Dealing with feelings can be as simple as validating how difficult it is.”

Disclosures: Dr. Feldman is a consultant, researcher, speaker or some combination for AbbVie, Amgen, Janssen, Galderma, Pfizer, Novartis, Celgene and Eli Lilly. Dr. Fried has been involved in clinical trials with Janssen and Amgen. 

Read more:

Psychosocial impact of psoriasis: The statistics

Psoriasis from the patient's perspective

Psoriasis stress response in vitro