Stefano Tabolli

Studies conducted using different tools have invariably observed that physical and mental components of health status are seriously compromised in patients with pemphigus. An improvement in quality of life (QoL) has been commonly observed over the treatment period. The aim of the study is to verify whether the patients' wellbeing is affected by pemphigus also in absence of cutaneous and mucosal lesions. The clinical records of 203 patients were analysed. A total of 47 patients were without bullae/erosions and reported a score = 0 for both the Patient Global Assessment and the Ikeda index. In order to assess the QoL we used the Skindex-17 and the 12-item General Health Questionnaire (GHQ-12). Patients without bullae/erosions had a better QoL when compared with patients with active lesions. This difference, with a reduction of approximately 30% of the Skindex-17 scores in the patients without lesions, was statistically significant, for both the symptoms and the psychosocial scales. The proportion of patients at risk of anxiety/depression (GHQ-positive cases) was 44% lower in patients without lesions compared with patients with lesions. In a multiple linear regression model the presence of bullae/erosions negatively influences QoL with an average increase of Skindex-17 symptoms and psychosocial scale scores of 11·7 and 10·6 points, respectively. Female patients had a statistically significantly worse QoL than males on the symptoms but not on the psychosocial Skindex-17 scales. While patients without lesions reported a better QoL than patients with bullae/erosions, their Skindex-17 scores remained elevated. Dermatologists should be aware that a clearing of the skin manifestations does not mean 'perfect health' for the patient.

Androgenic alopecia (AGA) is viewed as a relatively mild dermatologic condition; however, affected individuals feel that alopecia is a serious condition with major consequences in their life. The objective of this study was to assess the health status, the risk of anxiety/depression, the coping strategies, and alexithymia in subjects with AGA. Consecutive subjects referred to the outpatients department of the Istituto Dermopatico dell’Immacolata, Istituto di Ricovero e Cura a Carattere Scientifico (IDI IRCCS) dermatologic hospital with a diagnosis of AGA were enrolled. AGA was assessed using the Ludwig scale in female subjects and following Hamilton–Norwood’s classification in male subjects. The questionnaires provided to the patient and collected before the visit were the Medical Outcomes Study Short Form-12 (SF-12), the 12-item General Health Questionnaire (GHQ-12), the Coping Orientations to Problems Experienced (COPE), and the Toronto Alexithymia Scale-20 (TAS-20). Multiple logistic regressions were performed to examine the relationship of sociodemographic variables and clinical characteristics with coping. 351 subjects were enrolled during the study period. Sixty percent of female subjects with AGA were GHQ-12 positive (values ≥4) compared with 32 % of male subjects with AGA. AGA male and AGA female subjects had a statistically worse score than non-AGA male subjects for the physical component summary (PCS) and the mental component summary (MCS) of the SF-12, and for the GHQ-12. Compared with male subjects, AGA female subjects were more likely to adopt an ‘active emotional coping’ strategy according to COPE scores, and less likely to have ‘externally oriented thinking,’ and more ‘difficulty identifying feelings’ according to the TAS-20 scores. In a logistic regression model, including sex, MCS, total TAS-20, and the COPE scores as independent variables and the AGA severity as a dependent variable, only sex had a significant odds ratio (OR) [13.32; 95 % CI 4.77–38.58, p < 0.001]. Female subjects were almost 13 times more likely to have more severe AGA than male subjects. In three other models (i.e., one for each coping category) which included sex, AGA severity, MCS, and TAS-20, the ‘problem-focused coping’ strategy was negatively associated with alexithymia (OR 0.48; 95 % CI 0.27–0.86, p = 0.01), the ‘active emotional coping’ strategy was associated with gender (women had an OR of 2.69; 95 % CI 1.5–4.8, p = 0.001), and the ‘avoidant coping’ strategy was associated with alexithymia (OR 4.12; 95 % CI 2.23–7.58, p < 0.001) and with lower MCS values (OR 0.37; 95 % CI 0.22–0.64, p < 0.001). The study confirmed the high prevalence of depression/anxiety in AGA subjects, with a significantly higher prevalence in AGA female than male subjects. It is interesting to observe that patients reactions to their AGA related more to the emotional and psychological states deriving from their alopecia than to the objective clinical rating. Avoidant coping strategies were selected more frequently by AGA subjects if they were GHQ-12 positive and had alexithymia. To have alexithymia modified all coping strategies in AGA female subjects but not in AGA male subjects. Physicians should be aware that the impact of AGA is not limited to symptoms, and should help people to deal with their emotional responses to alopecia, such as anger and worry, and their beliefs about the consequences of their condition, and how it will impact on their daily life.

Background Emotional writing is a short-term psychological intervention that has been successfully used in several controlled studies.\ud \ud Objectives The overall objective of the study was to test the efficacy of Pennebaker’s emotional writing intervention in patients with psoriasis treated with systemic therapy.\ud \ud Methods A randomized controlled trial was conducted in seven clinical centres in Italy, over a 2-year period. The main outcome measures were the psoriasis area and severity index and the Physician Global Assessment, as well as generic and dermatology-specific quality of life questionnaires. Such outcomes were measured at 4 weeks, and 6 and 12 months from baseline. The project recruitment time was 12 months, and the total follow-up time for each individual was also 12 months.\ud \ud Results In total, 202 patients were enrolled and assessed at baseline, 67 of whom completed all three follow-up visits. The writing exercise had little or no effect on patients with psoriasis who were undergoing systemic treatment. In the Generalized Estimating Equations models no statistically significant differences were observed in the Pennebaker intervention group vs. the control group. In subgroup analysis for health status, small effects in favour of patients assigned to the Pennebaker group were documented at the end of the study in women, in overweight individuals, in patients under treatment with biological drugs, and on the Physical Component Summary of the Short Form of the Medical Outcomes Study Questionnaire.\ud \ud Conclusions The Pennebaker and control groups had similar changes over time for practically all the outcome variables, and also when considering all observations and adjusting for all the variables of interest. The longitudinal analysis confirmed that the intervention had little or no effect on the variables of interest. The implementation of writing exercises requires a careful and ad hoc organization, including dedicated spaces for the writing itself

Health status, health services utilization and mortality differ by marital status for both sexes in most conditions, but little is known about dermatological diseases. We evaluated whether marital status is associated with the impact that dermatological diseases have on quality of life (QoL). Data from two surveys on dermatological outpatients were pooled. Marital status, sex, age, and educational level were analysed in relation to QoL (using the scales of the Skindex-29 questionnaire: emotions, symptoms, and functioning) and psychological well-being (using the GHQ-12 questionnaire). Data on 5,471 patients (59% females, 46% married) were obtained. Married patients in univariate analysis had lower mean values on the emotions scale and higher mean values in the symptoms scale of the Skindex-29 compared to singles. Statistically significant differences were identified only in men, for the emotions scale and for the GHQ-12. Females had significantly higher mean scores than males on each of the Skindex-29 scales and on the GHQ-12. Married patients had a lower disease impact on the emotions scale even if they suffered a higher impact on the symptoms scale. However, after multiple adjustment, gender seems to be more relevant than marital status in the evaluation of health status.

Quinti I, et al. Yonsei Med J. 2012 May;53(3):603-610. http://dx.doi.org/10.3349/ymj.2012.53.3.603

Background In dermatological research and clinical practice it is important to evaluate the burden of the disease. Objective To assess whether the 12-item Short Form of the Medical Outcomes Study (SF-12) could yield a valid description of the health status of a large number of dermatological outpatients. Methods The SF-12 and the 12-item General Health Questionnaire (GHQ-12) were utilized. Questionnaires were self-completed by the outpatients in the waiting rooms. At the end of the visit the dermatologists recorded the diagnosis and the evaluation of the clinical severity. Results Data were complete for 2499 patients. We observed a reduction in the Physical Component Summary score (PCS-12) with increasing age, while the Mental Component Summary score (MCS-12) was stable. PCS-12 and MCS-12 scores were worse in women. Twenty-three per cent of patients were identified as GHQ-12 positive. GHQ-12-positive patients (‘cases’) had lower PCS-12 and MCS-12 scores compared with GHQ-12-negative patients (mean ± SD, PCS-12: 47·9 ± 10·8 vs. 52·2 ± 6·6; MCS-12: 35·2 ± 10·2 vs. 50·9 ± 78·3, respectively). High correlations between the MCS-12 score and the GHQ-12 were documented overall (−0·690, P < 0·001) and for single skin diseases. Conclusions The impact of dermatological diseases is high for the mental components of health status; the mean scores for MCS-12 were low, and lower in patients identified as GHQ-12 ‘cases’. The picture of the general health status of patients with skin diseases given by the SF-12 allows meaningful comparisons both within dermatological conditions and with diseases in other specialties, as well as within categories of clinical severity and psychological well-being in single skin conditions.

Background The assessment of a patient’s disease severity is an essential component in the formulation of treatment strategies. Objectives To compare disease severity assessment by patients and by physicians, and to describe the possible discrepancies between them. Methods For each patient, we obtained the Physician Global Assessment (PhGA) and the Patient Global Assessment (PtGA). Data were completed for 2.578 patients. Sixty‐one physicians participated in the study. We calculated the agreement between PtGA and PhGA scores using the weighted kappa statistics; a multinomial logistic regression was performed to assess the risk of disagreement considering both patient and physician variables. Results Differences in the percentages of severity level, identified by patients and by physicians, were always statistically significant (P < 0.05). Overall, the weighted Cohen’s kappa was in the range of 0.09–0.34, depending on the diseases. Gender differences between patients and physicians did not influence the agreement. In the multinomial model female patients (OR = 1.38; 95% CI, 1.07–1.77), patients with higher educational levels (OR = 2.71; 95% CI, 2.12–3.46), and patients with impaired quality of life (OR = 1.56; 95% CI 1.23–1.97) had a higher risk to be underestimated for their disease severity by physicians, independently by physician gender and experience. Conclusions Combining the subjective report with the objective severity assessment of the lesions, dermatologists may reach a better determination of how severity of disease is perceived by their patients and how they feel about the effectiveness of treatment. PtGA and PhGA might be considered in routine clinical assessments and not only for research activities.

Epidermolysis bullosa is a rare, inherited group of disorders characterized by blistering of the ski...

Epidermolysis bullosa (EB) is a rare, inherited group of disorders characterized by blistering of the skin following friction or mechanical trauma. EB has a clinical and socioeconomic impact on patients and their families. To assess the quality of life (QoL) in patients with EB and to determine disease burden. The study was an observational, cross-sectional postal survey. One hundred and eighty-five patients were invited to participate. Different sets of questionnaires [Short Form-36 (SF-36), Skindex-29, General Health Questionnaire-12 (GHQ-12), EuroQol 5 dimensions] were sent to patients according to age. The perceived severity of the disease was evaluated by patients or by the mothers of the younger children with EB, using the Patient Global Assessment five-point scale. Carers received the Family Strain Questionnaire. One hundred and twenty-five respondents were analysed. Patients with EB showed lower values in physical components of the SF-36, while the mental components were not significantly impaired. Among EB types, patients with junctional EB and severe generalized recessive dystrophic EB reported lower values and their GHQ-12 scores were significantly different from those of patients with EB simplex. There were no significant differences among EB types/subtypes for Skindex-29 values. Women had a worse QoL compared with men in all Skindex-29 and SF-36 scales (P < 0.05). GHQ-positive cases were more frequent among women (48%) compared with men (16%) (P = 0.003); GHQ-positive cases had a worse QoL compared with GHQ-negative patients. The patient QoL decreased and the family burden increased with increasing patient perceived disease severity and with increasing patient body surface involved. No differences were seen among EB types for the family burden. In patients with EB mental components of SF-36 scores are similar to the normal population. The perceived disease severity and skin area involved are relevant for QoL in all EB types/subtypes. EB imposes a heavy burden on the caregiver and the family. Psychological support and close monitoring of QoL may help patients with EB and their carers.

The therapeutic effects of some histological staining agents on psoriasis have been reported in the past. One of these agents is eosin, which is still currently used in routine treatment, although it has never been formally tested in a randomized controlled trial. Aim. To compare treatment with eosin in patients with moderate to severe psoriasis vs. short-course topical steroid, a well-defined, evidence-based treatment.A randomized trial was designed and conducted. The Skindex-29 and General Health Questionnaire (GHQ)-12 questionnaires, and Psoriasis Activity and Disease Index (PASI) were used before treatment in 43 patients. Five days after treatment, PASI was measured again.Five days after treatment, a significant mean reduction of PASI was observed in both groups: 6.8 (95% CI 5.5-8) for eosin, and 5.2 (3.2-7.1) for steroids. The difference between the two groups was not significant (P = 0.161).Eosin has a short-term effect similar to topical steroids. The low cost of eosin treatment and its limited collateral effects suggest that eosin could be an effective steroid-sparing agent in the initial phase of psoriasis treatment.