Psoriasis: Spelling the Real Challenge - Research Paper Example

? Psoriasis: Spelling the real challenge Stacy Willis Psoriasis: Spelling the real challenge Psoriasis is a lifelong, relapsing, and proliferative skin disorder that results from alterations at the genetic, immunologic, and biochemical level (Ignatavicius and Workman, 2010). Actually, both the exact cause and effective treatment of the disorder remain an important topic for debate even until today for medical practitioners and researchers (Kumar et al, 2010). The problem of the situation does not stem directly from the disease itself, but on the psychosocial perspective as well. Thus, acceptance of the situation is an indispensable ingredient to maximize the clients’ adherence to any therapy. In this paper, the efficacy of the available treatment options for psoriasis will be comprehensively examined including the social issues affixed and outlook of the situation. In doing this, an overview of the disorder comprising the causes, risks, and pathophysiology will be briefly discussed. The cure for psoriasis has been a lifetime dream for dermatologists and affected clients. The quality of life of clients afflicted with psoriasis suffers greatly within 5 to 10 years after onset. Although it is not transmissible to other people, the appearance of the lesions affects the clients' social functioning (Winterfield et al, 2005). Traditional therapeutic regimens are continuously challenged by more recent discoveries in biochemistry and immunologic medicine. Some forms of treatment, like phototherapy and topical therapy, are used as a combination therapy rather than used alone. In any case, minor and major adverse effects manifest themselves that limit the clients’ adherence to the prescribed therapy. Presently, medical practitioners continue to discover potential treatment options that would precipitate fewer side- effects. As the genetic correlation and immunologic alteration of the disorder are being studied, the use of biologic agents and gene therapy may become one of the treatment options in the future. Several scientists are becoming more and more aggressive in the treatment by using monoclonal antibodies purposely altered to suppress cell division of target cells (Winterfield et al, 2005). Pathophysiology The exact triggering mechanism involved in psoriasis consists of the dynamic interplay of individual factors and environment (Kumar et al, 2010). Although genetic predisposition to the condition has been recognized in some cases, the incidence of psoriasis remains relatively similar even in clients without a traceable family history. Moreover, the role of the environment as a risk factor can be seen in some clients when psoriatic lesions occur at areas with a history of skin injury, sunburn, and excoriation. Warm climates also appear to improve the condition (Ignatavicius and Workman, 2010). In addition, the immunologic causation of the condition can be observed in some clients who also developed debilitating arthritis. Because of this, psoriasis can be viewed as a systemic connective tissue disorder rather than a simple skin condition (McPhee et al, 2006). While it has been generally established that the onset of the condition occurs by 20 years of age, the condition may also manifest in older people at 57 to 60 years of age. Psoriasis is very common and affects nearly 1% to 2% of the population (Huether and McCance, 2006). The pathophysiologic basis of psoriasis highlights the involvement of an abnormality in the immune reaction in the skin which results from the overstimulation of the immune system (Kumar et al, 2010). Langerhans cells in the skin react with an unknown antigen, leading to T- lymphocyte activation which then attacks the keratinocytes. The resulting dermal inflammation causes scaling (McPhee et al, 2006). Normally, the cells in the basement membrane of the epidermis reach the outermost layer for about 27 days, while it only takes 4 to 5 days in the case of psoriasis. Cell maturation and keratinization are bypassed, thus the epidermis thickens and plaques form. Loosely cohesive keratin gives the lesion a silvery appearance. Capillary dilation and increased vascularization accommodate the increased cell metabolism and cause erythema (Huether and McCance, 2006). Psoriatic lesions vary in appearance, size, or color. One type of psoriasis, called Psoriasis vulgaris, produces sharply demarcated thick reddened papules covered by silvery white scales. Another type, called Exfoliative psoriasis, presents as an inflammatory form with generalized erythema and scaling but without obvious lesions (Ignatavicius and Workman, 2010). Arthritis develops in about 5% of the time (Winterfield et al, 2005). Treatment Issues It is important to note that until now, there has been no single medicine that could treat the condition completely (Ignatavicius and Workman, 2010). Available treatments are only suppressive therapy. Clients usually decide which option to undergo to control the condition. When the necessary information are given about the efficacy of treatment, the decision to not do anything other than avoiding the provoking factors usually come at hand. With this, several issues have emerged in the efficacy of the therapies available. The lifetime adherence to therapy ultimately drains the motivation, emotional support, and financial resources of the client. Recent improvements in the management of psoriasis focus on the development of a standardized objective measurement to assess the extent and severity of the condition. The traditional use of Body- Surface Area (BSA) classifies psoriasis according to the percentage of body surface involved. Severe psoriasis is diagnosed if more than 20% of the BSA is affected with psoriatic lesions (Winterfield et al, 2005). Another tool, Psoriasis Area and Severity Index (PASI), is used to assess the efficacy of treatment used by considering the degree of lesional erythema, induration and scale, and BSA of four specific body regions. Instead of classifying the condition as "severe" based on the BSA involved, under PASI, the lesions should also be examined (Winterfield et al, 2005). Basically, the treatment for psoriasis is related to reducing epidermal cell turnover and immune-modulation. The goal of treatment revolves around decreasing the debilitating effects of the disorder in a client’s activities of daily living (Ignatavicius and Workman, 2010). Medical interventions may do more harm than good, and thus deserved a careful examination before used in the clients. Although psoriasis causes extreme emotional distress for the clients, it is usually a minimal physiological disease. Medications used in psoriasis have several major side effects that compromise the client’s immune reaction and multiple organ function. Specifically, some indicators often dictate whether appropriate treatment is needed. The presence of local symptoms including pain, intertrigo, aesthetic problems, and itching may require further medical intervention. Depending on the severity of the case, the client’s distress and response to treatment, and the physician’s preference, the therapeutic choices revolve around topical, ultraviolet light, and systemic therapy. Topical therapy The initial treatment for psoriasis involves the use of topical therapy. Clients with less than 10% affected skin surface area and have stable psoriasis may still respond positively (Ignatavicius and Workman, 2010). Topical therapy includes the application of topical steroids, keratolytic agents, emollients, anthralin, calcipotriene, and tar preparations (Greaves and Weinstein, 1995). Corticosteroids are administered directly to the lesion followed by application of warm, moist dressing with an occlusive wrap. These agents are effective in suppressing cell division and reduce inflammation. Corticosteroids are by- far the most effective treatment for psoriasis for several reasons (Ignatavicius and Workman, 2010). Clients usually comply with topical application of corticosteroid because it does not cause any irritation or staining, it is readily available at relatively low cost, and acts faster than the other treatments. An important social issue to be addressed related to the use of corticosteroid is the increased incidence of side- effects. Some side- effects expected with any corticosteroid use include masking of infection, thinning of the skin, and formation of striae, decreased skin pigmentation, and relapse. Since corticosteroids suppress the overall immune response, other local infection may not be detected due to its compromised function. These side- effects depend on the potency of the corticosteroid used. Some corticosteroids cannot provide a long- term effect, and clients usually experience a relapse (Greaves and Weinstein, 1995). Aside from corticosteroids, tar preparations are used to suppress the cell division and reduce inflammation. Commercially prepared coal tar is available as lotions, gels, shampoos to prevent scaling of the scalp, and other solutions directly applied to the affected area (Ignatavicius and Workman, 2010). However, the efficacy of tar application is not as good as corticosteroids. It can cause irritation and eruptions on the normal skin. Besides that, tar also has an unpleasant odor and looks dirty, thereby limiting the clients’ compliance to the treatment. Emollients such as a soft yellow paraffin, aqueous cream, and petrolatum are effective in maintaining hydration and softening of the surfaces of psoriatic lesions through the reversal of the inflammatory consequences of damage to the stratum corneum. This layer of the skin suffers an extensive damage due to loss of moisture content and scaling. Emollients can be considered as a weak form of treatment, although it significantly reduces itching, inflammation, and erythema. It is usually applied twice on a daily basis. The major drawback of this kind of treatment is that causes shininess and stickiness of the treated skin (Greaves and Weinstein, 1995). Aside from this reason, dermatologists usually prescribe an adjunct form of treatment because emollients act only to alleviate the symptoms. These agents do not cure the disease. Some clients still suffer emotional distress even when applying emollients for a longer period because of feelings of hopelessness. On the other hand, keratolytic agents such as salicylic acids are also used to alleviate the signs of psoriasis. Like emollients, salicylic acids soften the scaly layers of psoriatic plaque and ease their removal. Because of this, it is commonly used together with corticosteroids and coal tar as it enhances the contact and absorption of these agents with the lesions. However, there is no available documentation yet as to the efficacy of this treatment if used alone. Thus, keratolytic agents may not have direct effects on the lesions but only facilitates the action of other treatment (Greaves and Weinstein, 1995). In many European and US centers, anthralin has been the ideal choice for treatment of long standing psoriasis following the Ingram specifications. This would include a daily coal- tar bath, UVB, and round- the- clock application of anthralin paste with salicylic acid to prevent its inactivation. Comparative analysis of the efficacy of these daily procedures showed relatively similar values in terms of duration of action and cost. Like tar, anthralin may produce brown and purple products when oxidized, which in turn stain the skin and clothing (Greaves and Weinstein, 1995). Mild to moderate psoriasis can be relieved using vitamin D derivatives like calcipotriene. The use of this drug turns to be a new trend in topical therapy of psoriasis in Europe and US. While it is an analog of vitamin D, it has negligible effects on calcium metabolism. The effect of calcipotriene is similar to that of a medium- potency corticosteroid ointment. It is colorless and odorless and is only mildly irritating. However, the rate of relapse and other side- effects have not been evaluated yet (Greaves and Weinstein, 1995). Phototherapy On the other hand, ultraviolet light therapy has been seen as an important component of therapy for psoriasis. Ultraviolet radiation is a physical agent commonly used as a topical treatment in many skin conditions (Ignatavicius and Workman, 2010). Traditionally, the use of ultraviolet B light is the most frequently used therapy for patients with moderate- to- advanced psoriasis. This form of therapy is effective within two to three weeks using 300 to 320 nm together with coal tar applications. While this therapy has been considered as the most effective form of phototherapy, the rate of relapse can be extremely high and can reach up to 80% of the cases. The risk of skin cancer is generally lesser, but the repeated exposure (up to 30 treatment sessions) to obtain desire results can be costly and impractical for the client (Greaves and Weinstein, 1995). Ultraviolet B (UVB) light produces more energy, compared with ultraviolet A (UVA) light. UV cabinets utilizing artificial UV are preferably used for easier control of the intensity and duration of exposure (Ignatavicius and Workman, 2010). In an outpatient basis, clients may benefit from Psoralen and UVA (PUVA) treatment. Psoralen is a photosensitizing agent taken 2 hours before exposure to UVA light. Exposure is adjusted based on the individual response, but usually limited to two to three times a week and not given on consecutive days. Because of strong photosensitizing effect of psoralen, clients are advised to wear sunglasses during treatment and remainder of the day (Ignatavicius and Workman, 2010). PUVA is regarded as highly effective especially in controlling extensive form of psoriasis. In most cases, skin lesions disappear after 20 to 30 treatments combined with chemotherapy. Some side- effects manifest even on short- time basis that includes nausea, burning, and itching. Adverse effects of long term exposure to UV include premature aging of the skin, actinic keratosis, and increased risk for skin cancer. The major disadvantage with PUVA is the increased frequency of skin carcinoma. In addition, the risk for genital skin cancer is much higher in men if appropriate shields are not placed over the genital and inguinal areas (Greaves and Weinstein, 1995). Systemic therapy The option for systemic therapy is reserved for clients with severe cases of psoriasis that is resistant to topical therapy. With systemic therapy, cytotoxic drugs (such as methotrexate), immunosuppressants (such as systemic corticosteroids), vitamin D derivativs, and vitamin A analogs are administered to control the cell division. Methotrexate is a folic acid antagonist that blocks DNA synthesis, thereby inhibiting cell proliferation in rapidly dividing tissues including hyperproliferative psoriatic epidermis and the gastrointestinal and germinative epithelium. Oral administration of methotrexate, at carefully controlled doses, inhibits replication of these cells with minimal side- effects (Ignatavicius and Workman, 2010). The immunosuppressive effect of methotrexate is thought to be related to its effect on the mononuclear cells in the skin, blood, or lymphatic tissues (Greaves and Weinstein, 1995). Guidelines for administration have been set according to the clients' hematologic status, liver, and renal functions to prevent overdosage, ensure drug clearance, and prevent systemic adverse reactions. Liver function tests are required before starting the therapy and annually thereafter since these agents are highly hepatotoxic. It is generally avoided for clients with bone marrow suppression, liver damage, and impaired renal function. When the plasma concentration of methotrexate becomes too high, leukopenia and erosions in the cutaneous and gastrointestinal tract are expected. If possible, the drug must be titrated to maintain the minimum therapeutic dosage. Since cirrhosis is essentially worse than psoriasis itself, cirrhosis of the liver should be avoided at all cost. That is, the treatment of the original condition must not predispose the client into another secondary chronic, potentially fatal condition. Because of this, the use of methotrexate is absolutely avoided for people with a history of liver disease or excessive alcohol intake. Aside from liver function tests, liver biopsy may be performed before therapy is begun. In contrast, current statistical data suggests that the rate of liver complications associated with methotrexate has significantly dwindled in the past decades due to more sophisticated and sensitive medical equipment (Greaves and Weinstein, 1995). Etretinate, on the other hand, is a retinoic acid analog that stimulates epithelial differentiation and inhibit malignant transformation in skin and mucous membranes. Most scientists agree about the importance of retinoic acid in the integrity of skin cells. Literature suggests the role of retinoids in regulation of gene expression by directly influencing RNA transcription. Issues about the efficacy of etretinate are related to its decreased effect when used alone. Like the other treatment options, etretinate is better used with PUVA for chronic plaque psoriasis (Greaves and Weinstein, 1995). Retinoids may cause some side effects such as cheilitis, skin peeling, alopecia, xerosis, rhinitis, nail dystrophy, and even epistaxis (Winterfield et al, 2005). Bone abnormalities have been examined with long- term use. Nevertheless, etretinate has been persistently prescribed by dermatologists even if clients’ compliance to treatment remains apparently low. The use of systemic corticosteroids is also a treatment option for psoriasis. Cyclosporine is given to counteract the autoimmune basis of the disorder (Ignatavicius and Workman, 2010). It inhibits the synthesis of interleukin- 2 needed for an active immune response. Rapid improvements can be seen in clients with extensive psoriasis even for only two weeks of treatment. However, controversies between the balance of its therapeutic and adverse effect limit the use of the drug. When used for more than one year, cyclosporine causes irreversible hypertension and compromised renal function. The incidence of relapse increases even after the whole year of treatment when not used within three months. Thus, the therapeutic effect of cyclosporine is limited for one year only, and major side- effects start to manifest thereafter. Unlike the other treatment options, cyclosporine is not used together with the UV and other carcinogenic treatment (Greaves and Weinstein, 1995). While dermatologists hesitate to prescribe the drug, clients still prefer it because of rapid improvement of the condition. In these cases, it is vital that the clients are well- informed of the potentially disastrous adverse effects of the drug. While cyclosporine claims positive promise for the relief of psoriasis, the overall effects on the health status should not be taken for granted. Recently, biologic agents like alefacept (Amevive) and efalizumab (Raptiva) have been approved for use in clients with psoriasis. These biologic therapies are given to alter the acquired immune response, thereby preventing overstimulation of keratinocytes. The use of biologicals has been supported by the immunopathogenesis of psoriasis. Since the altered pattern of immune response is now well understood, biological agents are genetically designed to interfere with T cell activation and effector functions. Biological agents act on the complex biochemical processes to reduce the number of pathogenic T cells by promoting apoptosis of activated memory T cells. Similarly, these agents also cause immunosuppression that increases the risk for infection (Ignatavicius and Workman, 2010). Social Impact The quest for the effective control of psoriasis does not dwell only on the pathologic basis of the disease but on the psychosocial impact as well. Clients affected by the condition usually suffer more from decreased self- esteem due to the several reasons. The treatment choices are very limited to the control of the lesions while posing extreme threats to the integrity of the whole body system. Research suggests that the complications from the treatments used in the management of psoriasis, as well as relapse rates, add up to the frustration and psychological distress of the clients (Krueger et al, 2001). Stigmatization is often experienced by people affected with psoriasis. One study reveals that the experience of stigmatization (EOS) is surprisingly higher in psoriasis than any other dermatologic condition (Vardy et al, 2002). Although psoriasis is not infectious, people afflicted with the disorder often face negative remarks from other people. This information supports the idea that psoriasis does not only need a physiological treatment, but psychosocial as well (Vardy et al, 2002). Behavioral scientists and psychologists focus on the impact of the disorder to the quality of life of affected individuals. Several tools to measure quality of life (QoL) consider the multifactorial perspectives of the condition. Categories are often used to obtain a more objective data from the clients’ subjective responses. These include psoriasis- specific, skin- specific, generic QoL measures, and mixed measures (Bhosle et al, 2006). Psoriasis- specific measures of QoL have been used in several researches to objectively determine the impact of the disease. Variations in the parameters can be seen in different models which give different levels of focus on a specific factor. Some models developed for research-purposes include Psoriasis Index of Quality of Life (PSORIQoL), Psoriasis Life Stress Inventory (PLSI), Psoriasis Disability Index (PDI), and Psoriasis Area and Severity Index (PASI) and Simplified PASI (SAPASI) (Bhosle et al, 2006). Under the psoriasis- specific category, these tools vary with each other at a certain extent. For instance, Psoriasis Index of Quality of Life (PSORIQoL) is grounded on the “needs- based” theory that prioritizes the adaptive capacity of affected individuals to maintain satisfaction of their needs despite their bio- social limitations. Since the adaptation to the disease varies considerably with each person, the PSORIQoL measures the personal impact of the disorder rather than the disability which appears to be highly generalized in the population (Bhosle et al, 2006). Another variant of the psoriasis- specific measures is the Psoriasis Life Stress Inventory (PLSI) tool. This tool is basically a 15- item questionnaire that measures individual adjustment to the daily social demands while having the disease. Unlike PSLI, the clients’ responses to questions in Psoriasis Disability Index (PDI) are descriptive (Bhosle et al, 2006). Skin- specific measures are another category to evaluate the quality of life of psoriasis clients. Examples under this category include Questionnaire on Experience with Skin Complaints (QES) and Dermatology Life Quality Index (DLQI). QES is specifically concerned with the impact of having altered skin integrity in the social life of affected people. It presents as a 23- item instrument. Likewise, DLQI presents as a self- report rather that a closed- response questionnaire (Bhosle et al, 2006). Generic QoL measures include Short Form 36 (SF-36), Subjective Well Being Scale (SWLS), and EuroQoL 5D (EQ-5D). The goal of generic QoL measures is to demonstrate that the impact of psoriasis is similar to other known chronic conditions. The SF- 36 is a comprehensive survey that aims to evaluate the impact of the disease in eight domains of health status (physical activities, social activities, usual physical role activities, bodily pain, general mental health, usual emotional role activities, vitality, and general health perceptions) (Bhosle et al, 2006). SWLS is a brief, but general assessment of the individual satisfaction with life as a whole, rather than a specific life event. Alternatively, EQ- 5D assesses the individual perception of life based on their current health status. In this questionnaire, individuals are assessed into the quality of life they wish to have while having psoriasis (Bhosle et al, 2006). Lastly, mixed QoL measures comprise of a more sensitive questionnaire that examine the impact of psoriasis in the biopsychosocial aspect of their life. The Salford Psoriasis Index (SPI) includes the assessment of the extent of the condition itself by assessing the severity of psoriasis based on PASI measurement. Some complications as skin carcinoma and tumor growths in other organs like the liver and kidney are also examined using appropriate assessment tools for cancer. Another type of mixed QoL measures is the Koo-Menter Psoriasis Instrument (KMPI). Unlike other measurements, KMPI is a formal diagnostic algorithm used to identify whether psoriasis clients need a more psychological work- up to assist them in coping with the condition (Bhosle et al, 2006). The validity of QoL measurements has been studied by several medical practitioners and psychologists. In one study, the use of DLQI and SF-36 form are considered the most reliable tools in the assessment of the efficacy of treatments (Shikiar et al, 2006). Furthermore, the EQ- 5D has been recommended for general use in moderate- to- severe cases of psoriasis in the future. Conclusions Even for milder treatment using topical therapy of coal tar and emollients, aesthetic problems arise as these agents cause look dirty and have an unpleasant odor. Clothing stains add up to the emotional and physical distress of the client. Clients prescribed under this therapy frequently feel miserable and hopeless. Maladaptive coping responses, self- concept, and self- esteem are depressingly affected by the social stigma related to their appearance (Bhosle et al, 2006). Many people with psoriasis claim that unaffected people including their relatives and their own physicians do not understand the psychological suffering they have (Bhosle et al, 2006). Better communication between the clients towards the physician needs to be established through counseling. Open communication allows ventilation of feelings and help uncover other issues relevant to the compliance to the prescribed therapies (Krueger et al, 2001). Quality of life declines as social and vocational roles are not functionally sustained. Psoriasis may falsely be regarded as a contagious skin disease by people who do not have accurate knowledge of the condition. Although this is wrong, affected people face horrible public discrimination and feel alone in their lives. In fact, psoriasis has been one of the reasons of the rising incidence of depression and suicide related to medical condition (Bhosle et al, 2006). The chronic treatment of psoriasis also steals an enormous cost of healthcare. Financial concerns also stem from loss of productivity and absenteeism from work and livelihood. The future of management for psoriasis cannot be easily spelled out. A more detailed understanding of the condition demonstrated not only the need to study the immunopathogenesis and genetic involvement, but also on the therapeutic approach to promote understanding and acceptance of the client. Trends have been seen in using biologic agents, angiogenesis inhibitors, new retinoids, oral pimecrolimus, lasers, and photodynamic therapies. As the future holds the hope for a more effective treatment with fewer side- effects, collaboration of the medical practitioners, the social community, and the client remains to be a top priority. On the brighter side, information about psoriasis including its symptoms and treatment options has saturated both online and published medical literature. Because of the ease of access to information, people affected with psoriasis develop a personal opinion on the treatment options available. Accurate information is vital for the understanding of the public about the disease to prevent stigmatization and promote acceptance of the affected population. This is particularly important since the psoriasis is a chronic and often relapsing condition. Concerned people may also change their false opinions on the causation of psoriasis. The role of the society in the attainment of the optimum level of functioning should be promoted. The advantage of using the internet as an information portal cannot be underestimated. Information available in the internet differs in the complexity of language. Some websites generally use a form of language that is appropriate for the public. Some others use highly technical terms and use the internet as a tool of disseminating information about the results of their research. Improved patient- physician communication is an essential tool to maximize the effects of the treatments. Acceptance of the condition and appropriate knowledge of other people in the clients’ social circle can be a motivating drive during the most depressing moments. Indeed, the results of this research opened up vital issues about how a disorder can change the way we look at life. This research has enlightened the value of a simple hug and simple touch to a person who deeply needs it. Sometimes, studying a disease can block the emotional side of a person. But when we get to see people in reality affected with a certain condition, emotions flood up. Holistic care includes the psychosocial and emotional impact of a disease in a person. Truly, care for the people affected with the psoriasis should not settle around resolving it, but should incorporate the values of genuine concern, acceptance, and empathy. References Bhosle, MJ., Kulkarni, A., Feldman, SR. & Balkrishnan, R. (2006). Quality of life in patients with psoriasis. Health and Quality of Life Outcomes, 4: 35. doi:10.1186/1477-7525-4-35 Greaves, MW. & Weinstein, GD. (1995). Treatment of Psoriasis. New England Journal of Medicine, 332 (9): 581- 588. Huether, SE., & McCance, KL. (2006). Understanding Pathophysiology (3rd ed). St. Louis: Mosby. Ignatavicius, D.D. & Workman, M.L. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed). St. Louis: Mosby. Krueger, G., Koo, J., Lebwohl, M. et al. (2001). The Impact of Psoriasis on Quality of Life. Arch Dermatol, 137: 280-284. Kumar, V., Abbas, AK., Fausto, N. & Aster, JC. (2010). Robbins and Cotran Pathologic Basis of Disease (8th ed). Philadelphia: Elsevier Saunders. McPhee, SJ., Lingappa, VR. & Ganong, WF. (2006). Pathophysiology of Disease- An introduction to Clinical Medicine. San Francisco, California: McGraw-Hill. Shikiar, R., William, MK., Okun, MM. et al. (2006). The validity and responsiveness of three quality of life measures in the assessment of psoriasis patients: results of a phase II study. Health and Quality of Life Outcomes, 4:71. doi:10.1186/1477-7525-4-71 Winterfield, LS., Menter, A., Gordon, K. & Gottlieb, A. (2005). Psoriasis treatment: Current and emerging directed therapies. Ann Rheum Dis, 64(2): 87- 90. doi: 0.1136/ard.2004.032276 Vardy, D., Besser, A., Amir, M. et al. (2002). Experiences of stigmatization play a role in mediating the impact of disease severity on quality of life in psoriasis patients. British Journal of Dermatology, 147 (4): 736- 742. doi:10.1046/j.1365-2133.2002.04899.x Read More