See Psoriasis

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see psoriasis:look deeper Recognising the life impact of psoriasis


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people in theUK have

psoriasis 1Men and women

are affected equally 1

of people with psoriasis haveplaque psoriasis, which canappear on any part of thebody but most commonly itaffects the scalp, elbows,lower back, navel and knees 2

of those affected with psoriasisdescribe it as a problem orsignificant problem impacting

their quality of life3

Approximatelyone third experience

depression & anxiety 4

with moderate tosevere psoriasishave been foundto have problems

with alcohol 5

contemplate suicide 7,8

Approximately

people report beingrejected (and stigmatised as a result)because of their condition 9

experience feelingsof humiliation 10

A p p r o x i m

a t e

l y

work days per year may be lost;a third of patients also report

missing at least one day amonth and one in ten miss three

or more days a month due totheir health 11,12

feel annoyedwith their disease 10

of patients with severepsoriasis take anti-

depressant medication 6

1. The Psoriasis Association, What is Psoriasis, 2011, Accessed at: https://www.psoriasisassociation.org.uk/silo/ les/ No1%20what%20is.pdf Accessed on: September 2012

2. Grif ths CEM, Barker J. Pathogenesis and clinical features of psoriasis. Lancet 2007;370(9583):263713. Dubertret L, Mrowietz U, Ranki A, et al. EUROPSO Patient Survey Group. European patient perspectives on the impact

of psoriasis: the E UROPSO patient membership survey. Br J Dermatol 2006;155(4):729364. Kimball AB, Gieler U, Linder D, et al. Psoriasis: is the impairment to a patients life cumulative? J Eur Acad Dermatol

Venereol 2010;24:98910045. McAleer MA, Mason DL, Cunningham S. Alcohol misuse in patients with psoriasis: identi cation and relationship to

disease severity and psychological distress. Brit J Dermatol 2011;164:125612616. Meyer N, Paul C, Feneron D. Psoriasis: an epidemiological evaluation of disease burden in 590 patients. J Eur Acad

Dermatol Venereol 2010;24:107510827. Kurd SK, Troxel AB, Crits-Christoph P, Gelfand JM. The risk of depression, anxiety, and suicidality in patients with

psoriasis: a population-based cohort study. Arch Dermatol 2010;146(8):8915

8. Eedy D, Burge S, Potter J, et al, on behalf of The British Association Dermatologists and Clinical Effectiveness andEvaluation Unit, Royal College of Physicians Clinical Standards Department. An audit of the provision of dermatologyservices in secondary care in the United Kingdom with a focus on the care of people with psoriasis. January 2008.

9. Ginsburg IH, Link BG. Psychosocial consequences of rejection and stigma feelings in psoriasis patients. Int J Dermatol1993;32(8):58791

10. Sampogna F, Tabolli S, Abeni D, and the IDI Multipurpose Psoriasis Research on Vital Experiences (IMPROVE)investigators. Living with psoriasis: prevalence of shame, anger, worry, and problems in daily activities and social life.

Acta Derm Venereol 2012;92:29930311. Finlay AY, Coles EC. The effect of severe psoriasis on the quality of life of 369patients. Brit J Dermatol

1995;132:23624412. Schmitt JM, Ford DE. Work Limitations and Productivity Loss Are Associated with Health-Related Quality of Life but Not

with Clinical Severity in Patients with Psoriasis. Dermatology. 2006;213:102110.

References


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Anyone living with psoriasis will agreethat it is li e-changing.

For up to approximately 1.8 million people in theUK who are a ected by psoriasis, it is more than

just a skin condition. 1,2 The multi- aceted nature opsoriasis means the e ects go beyond visual signs andsymptoms. 2 It can impact on emotional and physicalwellbeing and in some people it is associated withdepression, anxiety and suicidal thoughts, particularlyin those a ected with more severe psoriasis. 3-6

Yet, despite the documented impact on emotionalwellbeing, these wider e ects o ten go unrecognisedand untreated. 5,7

We, the Psoriasis Association and the Mental HealthFoundation , have come together to raise awareness o the need or healthcare pro essionals to look atpsoriasis holistically, to consider both the physicalsymptoms and psychological wellbeing, and ensurepeople with psoriasis receive the care and support

they need. Some people with psoriasis o ten eel thattheir GP regards psoriasis as a minor skin complaintand are dismissive o the emotional aspects leaving many to continue unaided on the isolating andemotional journey associated with psoriasis. 5,7

This report is part o the See Psoriasis: Look Deeper campaign exploring psoriasis as a complex, progressivecondition which has numerous consequences or theindividual, their amily, and society as a whole. 2,3,4,8,9

We call or

The ull impact o psoriasis to be recognisedand treated by multi-disciplinary teams who willlook deeper, both literally and metaphorically,to ensure that the treatment people receiveaddresses all their health needs.

To create change, we need to

Prioritise political e orts to ensure thatthe nancial levers and incentives orcommissioners are aligned to multi-disciplinaryworking. Beginning with the National Institute

or Health and Clinical Excellence (NICE)guidance on the management o psoriasis,and ollowing through to the guidance issuedby the NHS Commissioning Board to thenew Clinical Commissioning Groups (CCGs),the NHS must support collaborative workingthat can respond appropriately to both thephysical and psychological needs o people

with psoriasis.

At the same time, we are calling on people withpsoriasis, and their amilies and riends, to considerthe broader impacts o the condition and be aware othe potential impact on psychological wellbeing andquality o li e. We ask them to not su er in silence, butto ask or help to ensure that they receive appropriatere errals and treatment when they need it most.

Helen McAteer, Chie Executive,Psoriasis Association

Andrew McCulloch, Chie Executive,Mental Health Foundation

Foreword

see psoriasis:look deeper

Together we can work towards improved holistic care for people with psoriasis.We just need to see beyond the skin and look deeper into their needs.


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Looking beyond the skin

*People with psoriasis submitted postcards for inclusion within the See Psoriasis: Look Deeper campaign describing how their psoriasis makes them feel and express the impact that the condition has on their life. People could choose to stay anonymous if they preferred.

Many people see psoriasis as a condition that only a ectsthe skin and impacts on appearance; they do not realise that the e ects can go much deeper and can have alasting e ect or those living with the condition day-to-day. 7 As a long-term condition a ecting many patients ormost o their adult li e, its unpredictable nature means itsimpact varies, so while some people manage or yearswithout a psoriasis fare, others are a ected regularly. 10

Similarly, the severity o psoriasis can vary enormously;some people have a single, isolated plaque that is barelynoticeable, yet others can be a ected in many di erentareas o the body. 10 Psoriasis plaques can be itchy orsore, and may cause the skin to crack and bleed. 11

Psoriasis is strongly associated with the risk oother health issues, urther adding to the di culty thatmany patients ace. Between 6% and 40% developpsoriatic arthritis sti ness, pain and swelling o the

joints, which may lead to de ormity; 12-15 whilst the risk odeveloping conditions such as cardiovascular disease,type 2 diabetes, depression and Crohns disease is alsoincreased. 2,14,15,16

P s o r i a s i s T h e F a c T s

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I t is a c h ron ic in a mm a t o ry d ise a se e s t im a t e d t o a e c t be t we e n 1.5% a nd 3

%

o f t he UK popu l a t ion, wh ic h me a ns t h a t up t o

1. 8 m i l l ion pe op le a re a e c t e d 1,2,4, 13, 1 7

90% o f pe op le w i t h pso r i a s is h a ve p l a q ue pso r i a s is wh ic h c a n a ppe a r on a ny p a r t o f t he body bu t mos t c ommon ly i t a e c t s t he

sc a lp, e l bows, lowe r b a c k , n a ve l a nd k ne e s 1 7

M os t pe op le a re m a n a ge d in P r im a ry C a re

w i t h t op ic a l t re a t me n t s; howe ve r, i f t he se

t re a t me n t s a re no t suc c e ss f u l, pe op le w i t h

pso r i a s is m a y be re f e r re d t o spe c i a l is t de rm a t o logy se r v ic e s f o r U V l igh t t he r a py,

sys t e m ic t re a t me n t s o r b io log ic s

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5/125*People with psoriasis submitted postcards for inclusion within the See Psoriasis: Look Deeper campaign describing how their psoriasis

makes them feel and express the impact that the condition has on their life. People could choose to stay anonymous if they choose.

Like it or not, we live in a society whereappearance matters, so it should come asno surprise that psoriasis impacts on thepsychological wellbeing as well as quality oli e or those who have to endure it. 2,4

Contrary to popular belie , these e ects arenot always related to or based on how severethe condition may be. For example, someonewith physically mild symptoms may havemore di culty coping than others with moresevere or extensive symptoms. 18 It essentiallyboils down to how each individual eels theycan cope and the support they have to do so.

The relationship between physical health and emotionalwellbeing is complex. Those with psoriasis can havelow esteem or su er rom depression and anxiety, andi unrecognised, these health issues can prevent people

rom e ectively managing their psoriasis. 19 Insteadthey may develop unhelp ul ways o coping such asavoiding being in public, excessively using alcohol andovereating. 19 These ways o coping can negatively a ectother health conditions associated with psoriasis, such asheart disease or diabetes. 19 It is this pain and discom orto psoriasis along with its emotional impact, which can

lead people with psoriasis into a cycle o despair.19

I dont want to be rejectedBecause o the obvious visibility o psoriasis, manypeople experience rejection and stigmatisation, 2 whichcan have a detrimental e ect on their sel -esteem.

Approximately one in fve people report being rejected (and stigmatised as a result o their condition). 20 Thishappens most o ten in public and in communal placessuch as the gym, swimming pool, at the hairdressers or atwork. 20

Sometimes I dont want to be around anymoreWorryingly, approximately one third o people living withpsoriasis also experience depression and anxiety. 2 Whatis more shocking, however, is that psoriasis is associatedwith an increased risk o suicidality. 3 Up to 1 in 10 peoplecontemplate suicide, highlighting the devastating e ectso the disease. 2,5,6,19

My everyday li e and amily are a ected A European-wide patient survey ound that 77% o thosea ected with psoriasis describe it as a problem or

signifcant problem in terms o impacting their qualityo li e.12 Simple activities such as cleaning the house ordoing the laundry, which are taken or granted by many,need to be done more requently. 9 Social lives andrelationships can also be restricted, urther adding to thepsychological pressure. 2, 21

It is not just the impact psoriasis has on the individualthat needs consideration. Psoriasis also signi cantlya ects amily and riends. 8,22,23 Around 90% o peoplewith a amily member or relative with psoriasis report that

their li e is adversely impacted a ecting social lives,holiday plans and time with other amily members. 8,23

Relationships, including sexual relationships, can alsobe a ected, even a ter symptoms have improved. 21

Drinking helps to numb the painThis impact on everyday li e and relationships can haveserious consequences and lead to excess alcohol use.Up to one third o patients with moderate to severepsoriasis have been ound to have problems withalcohol, 24 which can be extremely damaging as excessalcohol intake can increase the risk o other associatedconditions and lead to excessive mortality romalcohol-related causes in people with psoriasis. 24,25

My Psoriasis, My Pain

*People with psoriasis submitted postcards for inclusion within the See Psoriasis: Look Deeper campaign describing how their psoriasis makes them feel and express the impact that the condition has on their life. People could choose to stay anonymous if they preferred.

Im obe s e a n d pr e f e r t o s t a y t h a t wa y s o pe opl e s e e t h e f a t r a t h e r t h a n t h e ps or ia s is . L a ck of in t e r e s t a n d ca r e f r om my GP a d d s t o my l ow s e l f -e s t e e m. A f t e r h or r ibl e comme n t s in t h e s wimmin g pool , I d on t l ik e t o s wim a n d wi t h ps or ia t ic a n d os t e oa r t h r i t is s e t t in g in , l a ck of e x e r cis e a d d s t o t h e obe s i t y . E x t e r n a l l y I s mil e a n d t r y t o be jol l y ; in t e r n a l l y I l oa t h e my s e l f a n d wil l be gl a d wh e n l if e s ov e r .

A n on y mous *

I h a ve k nown you now f o r o ve r 4 0 ye a rs a nd

you ne ve r f a i l t o su rp r ise me . W he n you a re

good I f e e l on t op o f t he wo r ld a nd c on de n t ,

bu t w he n you a re b a d my c on de nc e p lumme t s

a nd I nd myse l f in a ve ry d a rk p l a c e f e e l ing

l i f e is no t wo r t h l i v ing. L e s le y *


6/126 *People with psoriasis submitted postcards for inclusion within the See Psoriasis: Look Deeper campaign describing how their psoriasis makes them feel and express the impact that the condition has on their life. People could choose to stay anonymous if they preferred.

Psoriasis - An emotional battle 2,5,6,19,20,21

Approximately one third experience depression

and anxiety2

Up to 85% o people eel annoyance with theirpsoriasis 21

1 in 3 experience eelings o humiliation abouttheir condition 21

1 in 5 people report being rejected (andstigmatised) as a result o their condition 20

1 in 10 contemplate suicide 2,5,6,19

A third experience problems with loved ones 21

P sor i a si s c a n a e c t t he ga i ni ng a nd r e t a ini ng o f pa i d wor k a nd li f e - t i me e a r ni ng po t e n t i a l2

A bou t one t hi r d o f pa t i e n t s, who a r e no t wor k i ng, de sc r i be be i ng una ble t o wor k due t o t he i r psor i a si s27

U ne mployme n t i s t hr e e t i me s mor e li k e ly f or pe ople a e c t e d wi t h psor i a si s t ha n f or t hose una e c t e d28

U p t o 26 wor k da ys pe r ye a r ma y be los t ;27 a t hi r d o f pa t i e n t s a lso r e por t mi ssi ng a t le a s t one da y a mon t h a nd one i n t e n mi ss t hr e e or mor e da ys a mon t h due t o t he i r he a l t h28

D ID yoU K noW..?>

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Work and economic woesWhen the ull implications o psoriasis are considered interms o economic impact, the gures are shocking. Onein fve people with psoriasis experience discrimination at work and one in our believes that psoriasis hasa ected their career choice. 9

Severe psoriasis requires people with psoriasis toregularly attend specialist clinics as well as phototherapysessions, which can take one to two hours each time, 9 or in some cases, stay in hospital or an average o 14days. 5 This can lead to di culties or those in demandingcareers which require long hours and close attention. As aresult, psoriasis is also associated with lower productivityand reduced income. 9 For many, the inability to enjoy a

ul lling career or employment and nancial stability canurther impact their psychological wellbeing.

There is also the overall impact and economic burden tosociety, which needs to be considered. The cost o adultmental health services in England is currently around6.6 billion. 26 There is now, more than ever, a need toprovide appropriate and e ective psychological supportto ensure the risk o long-term mental health problems

or patients with psoriasis is reduced and urther burdenon already stretched services is avoided.

Y o u a re w i t h m e d ay a nd n ig h t , 2 4 h o ur s.

E ve r y t h in g I d o is a f f e c t e d b y y ou. Y o u m a k e

m e fe e l un c o m fo r t a b le, u n t id y an d so m e t im e s e ve n

a s h a m e d. Y o u n e ver le t m e be f ree o f y o u r so ren e ss ,

u n s ig h t lin e s s , y o u r p a i n a n d u n p le a s a n t n e s s. R ic h ard *

I lost 2 j obs due to my ski n condi tion,durin g those years I was only worki n g for about 9 months per year due to i npati ent / out patient tr eatments for mychroni c

psori asi s. Hospital i n pati ent could beanythi n g up to 7 weeks at any one time i nthose days. T ime off work became a great burden (f inancially) on my youngwi fe andyoun g chi ldren.

Ri chard*


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Where are some of the opportunities? An urgent need (and opportunity) for better care

Although it should seem obvious that psoriasis can a ectan individuals psychological wellbeing, and evidenceshows that people with skin conditions such as psoriasisbene t rom psychological interventions, 29 sadly, an auditby the British Association o Dermatologists shows alack o ocus on the assessment and response to theseparticular needs. 5

With changes in the NHS underway, there is anopportunity to make a positive change that will bene tpeople with psoriasis. Successful treatment is more than

just management of physical symptoms ; assessmento symptoms and their impact on psychologicalwellbeing and social unctioning is vital when healthcare

pro essionals are considering the range o treatments andoptions.

When I was f i rs t di a gnosed wi t h psori asi s I really s t ru g gled. I f elt a gi t a t ed and s t ressed,whi ch would cause my psori asi s to worsen. As I

grew older, I found i t more and more di f f i cul t t o deal wi t h my condi t i on and by t he a ge o f 16 I was su f f eri n g wi t h severe depressi on and my con f i dence was a t an all t ime low.

T he day my derma t olo gi s t asked me f or t he f i rs t t ime: how does your psori asis a f f ec t you? and he heard how I was f eeli n g, he recommended t ha t I speak wi t h a counsellor. F or a lon g t i me I couldn t accep t t ha t I had psori asi s and i t was only t hrou gh wri t i n g my blo g and speaki n g t o o t hers t ha t Ive learn t

t o cope. Now I reali se tha t t here i s a whole ne t work around me who also have psoriasi s and my blo g has really helped t he people who are close t o me t o unders t and my psori asi s and how i t makes me f eel.

I f people could t alk t o each o t her and t hei r doc t ors abou t t he e f f ec t s o f psori asi s i t would be classed as a much more seri ous condi t i on

t hen i t i s a t t he momen t . F or me, psoriasi s i s more t han j us t a physi cal condi t ion and some t hi n g t ha t has a f f ec t ed me men t ally, and more awareness needs t o be rai sed. T he f ac t

t ha t my nurse and consul t an t unders t ood t ha t I needed psycholo gi cal help was t he mai n t urni n g poi n t for me.

Jessi ca

Clinical Commissioning Groups (CCGs)

Using these incentives and advice from NICE and theNHSCB, CCGs then need to ensure clear referralpathways are in place in their area, to help people withpsoriasis receive the best possible care.

Health and Wellbeing Boards (HWBs)

HWBs, established in every local authority, arerequired to undertake Joint Strategic Needs

Assessments (JSNAs) of their populations. Theseneed to take into account the level of co-morbidityamong people with psoriasis.

NICE Quality Standards

NICE has been tasked with developing a QualityStandard (QS) for Psoriasis that will be based onthe nal clinical guidance. The QS will drive andmeasure priority quality improvements within

psoriasis care, delivering the best possible servicesand outcomes for patients. Speedy development ofa Psoriasis QS is essential and it must consider themulti-faceted nature of this long-term chroniccondition and address its impact on psychologicalwellbeing and quality of life. A Psoriasis QS willensure:

Healthcare professionals make decisions aboutcare based on the latest evidence and bestpractice;

People with psoriasis receive high qualityservices and know what they should expect;

Providers of services know how well they areperforming; and

Commissioners are aware of what high quality,cost effective services for their patients look like.

NICE Clinical Guidance:The management of psoriasis

The nal guidance needs to include clear advice forthe NHS to consider the psychological impact of

psoriasis and ensure patients needs in this area aremet. As advocated by NICE Chair Professor Sir MikeRawlins, guidance should fully consider theco-morbidities associated with the condition andacknowledge the many different aspects of peopleslives that are negatively affected. 30

NHS Commissioning Board

From April 2013, most psoriasis services will becommissioned at a local level by the new CCGs.

Ministers retain responsibility for NHS servicesnationally via the NHS Commissioning Board(NHSCB), which will hold the CCGs to account for theservices they commission. The commissioningguidance issued from the NHSCB for CCGs needs toencourage the commissioning of multi-disciplinaryservices for psoriasis patients.


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A c k n o w l e d g e m e n t s

The Collaboration

Drs Chris Bundy and Sandy McBride are both members o the British Association o Dermatologists Psycho-dermatology working party led by Dr Anthony Bewley. This multi-pro essional group aims to identi y the service

needs and provision or people with skin conditions including psoriasis and improve the training or specialists inDermatology to better manage psychological and psychiatric aspects o skin conditions including psoriasis.

The Mental HealthFoundationThe Mental Health Foundation is theUKs leading mental health research,

policy and service improvement charity. It is committed

to reducing the su ering caused by mental ill health andto help everyone lead mentally healthier lives. It helpspeople to survive, recover rom and prevent mental healthproblems by carrying out research, developing practicalsolutions or better mental health services, campaigningto reduce stigma and discrimination and promoting bettermental health or us all.

Sandy McBrideDr Sandy McBride is a Consultant

Dermatologist at Royal Free HampsteadNHS Trust. She has an interest in thecomprehensive management o patients

with psoriasis and has set up one o the only integratedpsychology and dermatology services in the UK. Shewas awarded an NHS innovation award to develop theservice.

Psoriasis AssociationPsoriasis Association was ounded in1968 to provide in ormation, advice andsupport to people with psoriasis andpsoriatic arthritis. The organisation aims

to represent the views o patients at a local and nationallevel with an ever-expanding voice, and to remain awareo the issues that really matter to its membership and topeople whose lives are a ected by psoriasis.

Christine Bundy Dr Chris Bundy is a senior lecturer inBehavioural Medicine at the Universityo Manchester. Chris researches whatpsychological support works best or

people with psoriasis. With the rest o the Manchesterteam, Chris has developed online resources or peoplewith psoriasis in a study unded by the Psoriasis andPsoriatic Arthropathy Alliance. She designs and deliverstraining programmes or all dermatology specialist stato manage psychological aspects o psoriasis.

Pro essor Chris Gri fths,MD FRCP FMedSci Pro essor Chris Gri ths gained a 1 st classhons BSc in Anatomy and quali ed inMedicine rom St Thomas Hospital Medical

School, London University. He trained in Dermatologyat St Marys Hospital, London, and at the Universityo Michigan, USA, where he was also on Faculty or 4years. He was appointed to the Foundation Chair inDermatology at the University o Manchester in 1994 andis an honorary consultant dermatologist at Sal ord RoyalNHS Foundation Trust. Pro essor Gri ths developedthe hub-and-spoke model o dermatology services orGreater Manchester, and introduced a multi-disciplinaryclinic or severe psoriasis the Manchester PsoriasisService awarded Hospital Doctor Dermatology Team othe Year in 2002. At the University o Manchester he hasserved variously as: Head o Medicine and Neuroscience;Head o the School o Translational Medicine; ResearchDean and; Director o the Manchester Academic HealthScience Centre.

Pro essor Gri ths named lectureships include: SydneyWatson Smith (2006); Parkes Weber (2007); Von Zumbusch,Munich (2008) and; Hellerstrom, Stockholm (2010). Heis co- ounder o the International Psoriasis Council andis its President-Elect. He received the psoriasis li etimeachievement award o the American Skin Association in2009. The Times o London named him as one o the UKsTop 200 doctors in 2010 and in 2011 he was appointed asan NIHR Senior Investigator and elected to Fellowship o the

Academy o Medical Sciences.

Pro essor Gri ths has been President o : the British Association o Dermatologists (2004-5); EuropeanDermatology Forum (2010-11) and; British Society orInvestigative Dermatology (1997-2000). He serves onthe editorial boards o eight scienti c journals. He haspublished 425 Pubmed cited articles in scienti c journals,

has an H-Index o 73 and is senior editor o RooksTextbook o Dermatology. Pro essor Gri ths has long-standing research interests in all aspects o psoriasisincluding immunological mechanisms, immunotherapy,pharmacogenomics, and the brainskin axis.


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References

1. What is Psoriasis, 2011, Accessed at: https://www.psoriasisassociation.org.uk/silo/ les/No1%20what%20is.pd

Accessed: September 20122. Kimball AB, Gieler U, Linder D, et al. Psoriasis: is the impairment

to a patients li e cumulative? J Eur Acad Dermatol Venereol2010;24:9891004.

3. Kurd SK, Troxel AB, Crits-Christoph P, Gel and JM. The risk odepression, anxiety, and suicidality in patients with psoriasis: apopulation-based cohort study. Arch Dermatol 2010;146(8):8915.

4. National Institute or Health and Clinical Excellence. Psoriasis:the management o psoriasis. NICE guideline. Dra t orconsultation, May 2012. http://www.nice.org.uk/nicemedia/ live/12344/59182/59182.pd . Accessed: September 2012

5. Eedy D, Burge S, Potter J, et al, on behal o The British Association Dermatologists and Clinical E ectiveness andEvaluation Unit, Royal College o Physicians Clinical StandardsDepartment. An audit o the provision o dermatology servicesin secondary care in the United Kingdom with a ocus on thecare o people with psoriasis. January 2008.

6. Gupta MA, Gupta AK. Depression and suicidal ideation indermatology patients with acne, alopecia areata, atopicdermatitis and psoriasis. Brit J Dermatol 1998;139:846850.

7. Nelson PA, Chew-Graham CA, Gri ths CE, Cordingley L; TheIMPACT Team. Recognition o need in health care consultations:a qualitative study o people with psoriasis. Br J Dermatol 2012;doi: 10.1111/j.1365-2133.2012.11217.x. [Epub ahead o print]

8. Eghlileb AM, Davies EEG, Finlay AY. Psoriasis has a majorsecondary impact on the lives o amily members and partners.Brit J Dermatol 2007;156:12451250.

9. Meyer N, Paul C, Feneron D. Psoriasis: an epidemiologicalevaluation o disease burden in 590 patients. J Eur AcadDermatol Venereol 2010;24:10751082.

10. Patient UK. Psoriasis Fact Sheet. Accessed at: http://www.patient.co.uk/health/Psoriasis.htm on 13 September 2012.11. NHS Choices. Symptoms o psoriasis. Accessed at: http://

www.nhs.uk/Conditions/Psoriasis/Pages/Symptoms.aspx on 13September 2012.

12. Dubertret L, Mrowietz U, Ranki A, et al. EUROPSO PatientSurvey Group. European patient perspectives on the impacto psoriasis: the EUROPSO patient membership survey. Br JDermatol 2006;155(4):72936.

13. Ibrahim G, Waxman R, Helliwell PS. The prevalence opsoriatic arthritis in people with psoriasis. Arthritis Care Res2009;61(10):13731378.

14. Kimball AB, Gladman D, Gel and JM, et al or the NationalPsoriasis Foundation. National Psoriasis Foundation clinicalconsensus on psoriasis comorbidities and recommendations or

screening. J Am Acad Dermatol 2008;58:103142.15. Menter A, Gri ths CE, Tebbey PW, et al; International PsoriasisCouncil. Exploring the association between cardiovascular andother disease-related risk actors in the psoriasis population:

the need or increased understanding across the medicalcommunity. J Eur Acad Dermatol Venereol 2010;24(12):13717.

16. Az ar RS, Seminara NM, Shin DB, et al. Increased Risk oDiabetes Mellitus and Likelihood o Receiving Diabetes MellitusTreatment in Patients With Psoriasis. Arch Dermatol 2012;18:16. doi: 10.1001/archdermatol.2012.1401. [Epub ahead o print].

17. Gri ths CEM, Barker J. Pathogenesis and clinical eatures opsoriasis. Lancet 2007;370(9583):26371.

18. Russo PA, Ilche R, Cooper AJ. Psychiatric morbidity inpsoriasis: a review. Australas J Dermatol 2004;45(3):1559.

19. National Psoriasis Foundation Mental Health Issue Brie January2012. Accessed at: http://www.psoriasis.org/document.doc?id=350 on 10 September 2012.

20. Ginsburg IH, Link BG. Psychosocial consequences o rejectionand stigma eelings in psoriasis patients. Int J Dermatol1993;32(8):58791.

21. Sampogna F, Tabolli S, Abeni D, and the IDI MultipurposePsoriasis Research on Vital Experiences (IMPROVE)investigators. Living with psoriasis: prevalence o shame, anger,worry, and problems in daily activities and social li e. Acta Derm

Venereol 2012;92:299303.22. Basra MK, Finlay AY. The amily impact o skin diseases: the

Greater Patient concept. Br J Dermatol 2007;156(5):92937.Epub 2007 Mar 23.

23. Tadros A, Vergou T, Stratigos AJ, et al. Psoriasis: is it the tip othe iceberg or the quality o li e o patients and their amilies?J Eur Acad Dermatol Venereol 2011;25(11):12827. Epub 2011Jan 17.

24. McAleer MA, Mason DL, Cunningham S. Alcohol misusein patients with psoriasis: identi cation and relationship todisease severity and psychological distress. Brit J Dermatol2011;164:12561261.

25. Poikolainen K, Karvonen J, Pukkala E. Excess mortality relatedto alcohol and smoking among hospital-treated patients withpsoriasis. Arch Dermatol 1999;35:14901493.

26. Mental Health Strategies (MHS) or Department o Health.2010/11 National Survey o Investment in Adult Mental HealthServices. October 2011.

27. Finlay AY, Coles EC. The e ect o severe psoriasis on the qualityo li e o 369 patients. Brit J Dermatol 1995;132:236-244.

28. Schmitt JM, Ford DE. Work Limitations and Productivity Loss Are Associated with Health-Related Quality o Li e but Notwith Clinical Severity in Patients with Psoriasis. Dermatology2006;213:102110.

29. British Journal o Dermatology: A meta-analysis o thee ectiveness o psychological interventions or adults withskin conditions. The Department o Psychology, University oShe eld. 2009.

30. NHS National Institute or Health and Clinical Excellence,Newsroom.http://www.nice.org.uk/newsroom/news/ NICEShouldProduceGuidanceOnMultipleMorbidities.

jsp?textonly=true. Accessed October 2012

For more information on psoriasis or the importance of emotional wellbeing and quality of life, please visit the following websites:

Psoriasis Association Mental Health Foundation https://www.psoriasis-association.org.uk/ http://www.mentalhealth.org.uk/


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The initiative is funded by an educational grant from Abbott UK.

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