Patients’ needs and psoriasis treatment

Treatment of chronic relapsing skin diseases, where the presence of disfiguring lesions may be a major problem, is not an easy task even in the era of ‘biologics’. Are the patients really satisfied with treatment if lesions still persist? In assessment of psoriasis signs, both the dermatologist and the patient are based on their own experience. However, the patient's experience is normally limited to his own disease, while the dermatologist's experience is based on many different patients. Therefore, a relatively low level of the patient–dermatologist agreement in psoriasis severity and the symptoms reported by Griffiths et al.1 is not surprising. It is interesting to speculate why some psoriatic signs and symptoms revealed better patient–dermatologist concordance than others. According to the classic textbook description, psoriasis does not itch. Even in the mid-1980s, itch was considered as occasional and not a major complain of psoriatic patients. However, in the 21st century, itch is a common symptom reported by almost 80% of psoriatic patients.2 In addition to history by the patient, the dermatologist may try to study itch by looking at excoriations. Perhaps, this is the reason why the level of concordance was higher with regard to itch itself compared to itch intensity. When assessing joint pain and skin pain, the dermatologist has to rely exclusively on the patient's information. Therefore, the concordance level was higher. However, the question arises as to why the extent of skin pain and the presence of skin burning had a rather low level of concordance. More objective signs, such as nail pitting, skin discoloration or deformation and cracked skin, showed a moderate level of concordance. In contrast, redness or inflamed skin, scaling, bleeding and onycholysis showed only a low level of concordance. It would be interesting to know what patients understood as ‘inflamed skin’ or ‘onycholysis’. Minimal skin bleeding may be sometimes seen in fresh fissures on psoriatic lesions. However, at the time of consultation, it may not be observed and, therefore, neglected by the dermatologist. It is difficult to find an explanation for the low concordance with scaling. All these facts support the authors’ conclusion on the importance of further research to identify the drivers of patient–dermatologist concordance in psoriasis.1

Another important conclusion of the study is the need to further incorporate patient-centred strategies in treatment decision-making. For many years, dermatologists have been making attempts to include patients’ satisfaction into assessment of treatment efficacy. In 1972, Gahl and Comaish3 considered the clinical effect of psoriasis treatment as good in the case of appreciable lessening of the extent of lesions or scaling, or both, leading to a clear improvement of the patient's social or working life. In the age of ‘precision medicine’, the consideration of quality of life (QoL) allows a new dimension of individualized medicine regarding the very personal problems and needs of a patient.4 Griffiths et al.1 also informed readers that multivariable regression analyses on severity and satisfaction with psoriasis control were attempted in this study, which reveals that the patient's QoL (measured by the Dermatology Life Quality Index) may be associated with a change in the odds of alignment on satisfaction between patients and their dermatologist. By this statement, the authors underline that they consider this study together with another publication, where psoriasis patients with physical and psychological comorbidities, itching and affected visible and sensitive body areas had lower QoL compared to those without such conditions.5 A recent position statement of the EADV ‘task force on Quality of Life and Patient Oriented Outcomes’ described the many ways in which measuring QoL may be advantageous in clinical practice.6

Unfortunately, many publications do not provide exact data on single QoL items assessment. It is shown that even in the case of equal total QoL scores in terms of patients from different countries, the difference between single QoL items may be significant.7 This is in line with the authors’ conclusion on the importance of country-specific strategies.1 Country-specific differences due to economic, social and cultural factors should not be ignored. Nevertheless, all national healthcare systems should primarily seek to provide access to the best evidence-based treatment strategies for the patients in need.