Psoriasis and psoriatic arthritis (PsoA) often have a significant impact on the daily life and quality of life of those affected. The prevalence of mental health comorbidities is increased, with many suffering from depression and anxiety disorders. As a clinical implication of various empirical findings, it has emerged in terms of personalized medicine that the consideration of individual patient needs is of great importance.
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Psoriasis is associated with complex processes of cutaneous neuroimmune regulation: while stress leads to overactivation of the hypothalamic-pituitary-adrenocortical axis (HHNA) and an increase in proinflammatory cytokines, the cutaneous inflammatory response induces anxiety and depression through the associated disfigurement and stigma [1]. To find out more about the relationship between psoriasis and mental disorders, research teams from the Institute for Health Services Research, University Medical Center Hamburg-Eppendorf, conducted several studies [1,2].
Severe pruritus and anogenital involvement as risk factors
An observational study by Dr. Neuza da Silva and colleagues included adult patients with psoriasis vulgaris [1]. 107 subjects participated, the mean age was 46.3 years (± 14.6 years), 52.3% of the study participants were male. 40.2% of all participants suffered from moderate/severe pruritus (NRS≥4) and 29.0% were affected by anogenital psoriasis. The severity of psoriatic disease was assessed by PASI, and a numerical rating scale (NRS) was used to assess pruritus. The PHQ-2 (“Patient Health Questionnaire”) and the GAD-2 (“Generalized Anxiety Disorder”) were used to assess psychological limitations, with cut-off scores ≥3 as indicators of clinically relevant symptomatology of depression or anxiety disorder. Additional measurement tools used were DLQI (“Dermatology Life Quality Index”), PBI (“Patient Benefit Index”), DCQ (“Dysmorphic Concern Questionnaire”), PSQ (“Perceived Stigmatization Questionnaire”), and the RSS (“Relationship and Sexuality Scale”).
Statistical analyses revealed significant effects of moderate or severe pruritus compared with no or mild pruritus symptoms with respect to the following outcome parameters:
- Quality of life impairments (F=21.5, p<0.01).
- Anxiety disorders (F=5.6, p=0.02)
- body dysmorphic preoccupation (F=6.1, p=0.02).
- lower therapeutic benefit (F=12.7, p<0.01)
Moreover, moderate/severe pruritus had a stronger unfavorable effect on depression and stigma in patients with anogenital involvement (F=4.2, p=0.04; F=4.0, p=0.04 for the respective interactions). In summary, the results of the present study show that pruritus and infestation of anogenital body regions represent a high burden for psoriasis sufferers and may be trigger factors for coping strategies that provide short-term relief but may be problematic in the longer term (e.g., social avoidance behavior).
Mental disorders are common About 70% of adults affected by psoriasis vulgaris have at least one concomitant disease [4]. Up to 30% of patients develop psoriatic arthritis (PsoA) [2]. In addition, psoriasis is associated with an increased risk of cardiovascular and metabolic disease, inflammatory bowel disease, impairment of liver and kidney function, and mental disorders [5]. A Danish population-based case-control study published in 2019 found that psoriatic patients have a 75% higher risk of mental illness [6]. |
Depression in psoriasis patients as an indicator of PsoA development?
Up to 30% of patients with plaque psoriasis develop psoriatic arthritis (PsoA) during the course of the disease [2]. Claudia Garbe and colleagues conducted an analysis that aimed, among other things, to identify risk factors for the development of concomitant PsoA in psoriasis patients [3]. The data basis included information from more than 2 million insured persons of a large German statutory health insurance company (DAK-Gesundheit). First, the prevalences of psoriasis and PsoA in 2010 were determined, and second, the incidence of PsoA in the observation period (2011-2015) among insured persons with a first psoriasis diagnosis in 2011. In addition, the factors influencing the development of PsoA were determined by descriptive analyses of comorbidities and patient characteristics and by Cox regression modeling.
The prevalences of psoriasis and PsoA in the total adult population were 2.78% and 0.31%, respectively, with peaks among insured persons aged 50 to 79 years. In children, 0.16% (0-9 years) and 0.46% (10-17 years) were diagnosed with psoriasis. 2.5% of incisional adult psoriasis patients developed PsoA within five years of initial diagnosis. Within this period, the median time from psoriasis to PsoA diagnosis was 2.3 years. Psoriasis patients with or without concomitant PsoA had a comparable comorbidity profile, with cardiovascular disease being the most common comorbidity. Cox regression modeling revealed depression and neurosis/stress disorders as indicators of the development of PsA.
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Literature:
- da Silva N, et al: The importance of patient-centered healthcare against comorbid depression and anxiety in patients with psoriasis, P225, DDG Conference, 14.04.-17.04.2021.
- Chicken CK, et al: Skin inflammation with arthritis, synovitis, and enthesitis. JDDG 2019; 17(1): 43-66.
- Garbe C: Psoriatic arthritis (PsA): epidemiology, incidence, comorbidity profiles, and risk factor analysis. Depression as an indicator of PsA development in psoriasis patients? P243, DDG Conference, 14.04.-17.04.2021
- Augustin M, et al: Use of system therapeutics and biologics in guideline-guided the-rapy of moderate to severe psoriasis vulgaris. PsoNet Magazine 2017/1
- Kovitwanichkanont T, et al: Beyond skin deep: addressing comorbidities in psoriasis. Med J Aust. 2020 May 10. doi: 10.5694/mja2.50591.
- Leisner MZ, et al: Psoriasis and Risk of Mental Disorders in Denmark. JAMA Dermatol 2019; 155(6): 745-747.
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