What proportion of dermatological patients receive evidence-based treatment?

OBJECTIVE: To determine the proportion of dermatological patients who are offered evidence-based therapy in the routine dermatological practice. METHODS: For every patient seen for the first time at one of our tertiary hospital setting clinics between April and May 1999, the primary diagnosis and the primary intervention were recorded. For each primary diagnosis-primary intervention combination, evidence was searched for in electronic databases from January 1966 to December 1999. The proportion of patients who were offered evidence-based interventions was calculated as the main outcome measure. RESULTS: With a study sample of 136 patients, 61 different diagnosis-treatment couples were generated and 94 queries on electronic databases were performed (to account for "primary interventions" including more than 1 drug or treatment modality). Eighty-seven (64%) of 136 patients received evidence-based interventions. Evidence from randomized controlled trials was found for 69 patients (50.7% of the sample). Controlled studies lacking randomization or double blinding or including fewer than 20 patients per treatment group dealt with treatments offered to 14 patients (10.3%). The treatments offered to 4 patients (2.9%) were judged to have self-evident validity (ie, trials unanimously judged unnecessary). Symptomatic and supportive measures accounted for most interventions lacking substantial evidence (36% of the patients), but we had to include in this class other important treatment regimens, mainly for rare conditions. CONCLUSIONS: Most of the study patients received evidence-based care. However, published trials should be carefully appraised, and relevance of clinical end points should be evaluated together with methodological issues. More accessible, clinically oriented, evidence-based information sources are needed.

Age, gender, quality of life and psychological distress in patients hospitalized with psoriasis.

BACKGROUND: Psoriasis has a great impact on the quality of life of patients, and the ageing population is an important public health issue. OBJECTIVES: To investigate whether older patients with psoriasis have a different impairment in quality of life compared with younger patients, considering level of severity, duration of disease, gender and psychological distress. METHODS: The study was performed between February 2000 and February 2002 at the inpatient wards of the Dermatological Institute IDI-IRCCS, Rome, Italy, in the framework of a large project on clinical, epidemiological, emotional and quality of life aspects of psoriasis (IMPROVE study). This is a hospital-based cross-sectional study, with measures of quality of life (Skindex-29, Dermatology Life Quality Index and Psoriasis Disability Index) and of psychological distress, generic (12-item General Health Questionnaire) and psoriasis-related (Psoriasis Life Stress Inventory), all self-assessed by patients. We compared the mean scores of each quality of life instrument in patients aged < 65 years and >/= 65 years, in subsets of patients based on clinical and sociodemographic characteristics. RESULTS: We analysed 936 patients hospitalized at IDI-IRCCS with a diagnosis of psoriasis. Quality of life was significantly more impaired in the older group for all the Skindex-29 scales, and psychological distress was higher in older patients. In particular, older women suffering from anxiety or depression had the greatest impairment in quality of life. The results were somewhat different using the other quality of life instruments. CONCLUSIONS: These results should alert dermatologists that similar levels of clinical severity in psoriasis may be associated with different levels of quality of life and psychological distress of patients. Particular attention should be devoted to older patients, and especially to older women.

Stress, social support, emotional regulation, and exacerbation of diffuse plaque psoriasis.

The authors' aim was to investigate the role of stressful events, perceived social support, attachment security, and alexithymia in triggering exacerbations of diffuse plaque psoriasis. Inpatients experiencing a recent exacerbation of diffuse plaque psoriasis (N=33) were compared with inpatients with skin conditions believed to have a negligible psychosomatic component (N=73). Stressful events during the last year were assessed with Paykel's Interview for Recent Life Events. Attachment style, alexithymia, and perceived social support were assessed with the Experiences in Close Relationships questionnaire, the Toronto Alexithymia Scale, and the Multidimensional Scale of Perceived Social Support, respectively. Multiple logistic regression analysis was used to control for age, gender, education, marital status, and alcohol consumption. In relation to comparison subjects, the patients with psoriasis had lower perceived social support and higher attachment-related avoidance. Also, they were more likely to have high alexithymic characteristics. There were no differences between the patients with psoriasis and the comparison subjects in scores on the Experiences in Close Relationships anxiety scale, the total number of stressful events, and the number of undesirable, uncontrollable, or major events. Although caution should be applied in generalizing these findings to outpatients, this study suggests that alexithymia, attachment-related avoidance, and poor social support might increase susceptibility to exacerbations of diffuse plaque psoriasis, possibly through impaired emotional regulation. Several physiological mechanisms involving the neuroendocrine and the immune system might mediate the interplay between stress, personality, and diffuse plaque psoriasis.

Psychiatric morbidity in dermatological outpatients: an issue to be recognized.

BACKGROUND: There is a high prevalence of psychiatric disorders in dermatological outpatients. OBJECTIVES: To estimate the magnitude of this problem and to identify a set of variables associated with the presence of psychiatric disorder. METHODS: All adults attending the outpatient clinics of a dermatological hospital on predetermined days were given a questionnaire comprising the Skindex-29 and the 12-item General Health Questionnaire (GHQ-12). RESULTS: In total, 4268 questionnaires were given at admission, and 3125 were returned. Of these, 546 were blank or incomplete, leaving 2579 respondents (response rate 60.4%). Using a stringent cut-off threshold (> or = 5) for psychiatric case identification with the GHQ-12, scored in the conventional way, the overall prevalence of psychiatric morbidity was 25.2% (95% confidence interval 23.6-27.0%). We found a higher prevalence of psychiatric disorders in women and in widows/widowers, controlling for age. Health-related quality of life was a much stronger predictor of psychiatric morbidity than physician-rated clinical severity. High prevalence rates (> 30%) were observed among patients with acne, pruritus, urticaria, alopecia and herpesvirus infections, and in subjects without objective signs of dermatological disease. CONCLUSIONS: Our study has depicted the situation that is actually faced by dermatologists in their everyday practice, where they are in a unique position to recognize psychiatric morbidity and to take appropriate measures. The GHQ-12, being easy for patients to compile and for physicians or nurses to score, may be a practical tool to increase identification of patients with substantial psychological distress or formal psychiatric disorder in order to provide more comprehensive and appropriate intervention.

Treatment outcome and incidence of psychiatric disorders in dermatological out-patients.

OBJECTIVE: Epidemiological studies have shown that the prevalence of psychiatric disorders among dermatological patients is high. We aimed at estimating the short-term incidence of psychiatric disorders among patients with skin disease. METHODS: The 12-item General Health Questionnaire (GHQ-12) was used to identify subjects free from psychiatric morbidity at their first dermatological visit. The GHQ-12 was administered again after 1 month during a computer-assisted telephone interview. RESULTS: A total of 277 subjects was included in the study. At the follow-up interview, 21 (7.6%) were found to have significant psychiatric morbidity. Only lack of improvement was associated with increased incidence of psychiatric morbidity (13.6%), with an odds ratio of 3.1 (95% confidence interval 1.2-7.8), after adjustment for gender, age, educational level and clinical severity. CONCLUSIONS: Physicians should devote special attention to the risk of psychiatric complications in patients who have not improved with treatment.

The impact of skin diseases on patients: comparing dermatologists' opinions with research data collected on their patients.

BACKGROUND: Research data suggest that the detection of psychiatric disorders by dermatologists is not completely satisfactory, and that patients and dermatologists often assess patients' quality of life differently. Given that expectations influence perception and cognitia, these discrepancies might at least in part descend from conceptual models of skin disease that are prevalent among dermatologists. OBJECTIVES: We explored to what degree dermatologists' opinions about quality of life and prevalence of psychiatric disorders in several dermatological conditions corresponded to the actual data collected on their patients. METHODS: All dermatologists working in a large institution were asked to express on a five-point scale their opinion about the quality of life and the prevalence of depressive and anxiety disorders in different skin conditions. Physicians' opinions were then compared with the results of a large research project on quality of life and psychological well-being in dermatological out-patients performed in their institution some months before. RESULTS: Forty-six dermatologists (82%) agreed to participate and completed the research questionnaire. We observed a fairly good concordance between dermatologists' opinion about the impact of the various skin conditions on patients' lives and survey data on quality of life impairment. With regard to psychiatric morbidity, we found that dermatologists believe that psychiatric disorders are substantially less frequent than they actually are in many skin conditions. CONCLUSIONS: The belief that psychiatric morbidity is rare in patients with certain skin conditions might hamper, at least in part, the recognition of psychiatric disorders in these patients. Dermatologists probably should be more alert to the question of psychiatric morbidity in their patients. Allocating more space to this issue in training programmes for dermatologists might favour a shift in their conceptual models of skin disease.

Prevalence of symptoms experienced by patients with different clinical types of psoriasis.

BACKGROUND: The main dermatology textbooks describe only in passing pruritus in psoriasis and rarely mention other symptoms. A quantification of the presence of symptoms is not available for clinical subgroups of psoriasis. OBJECTIVES: To investigate the prevalence of symptoms experienced by patients with different clinical types of psoriasis. METHODS: The study was carried out in patients hospitalized for psoriasis between February 2000 and February 2002 at the inpatient wards of the Istituto Dermopatico dell'Immacolata, Rome, Italy. Symptoms were evaluated using the symptoms scale of Skindex-29. Clinical severity was assessed by the dermatologists using the Psoriasis Area and Severity Index (PASI), and by the patients completing the self-administered PASI. Psychiatric morbidity was evaluated using the 12-item General Health Questionnaire. RESULTS: In total, 936 eligible patients were analysed. The proportions of patients experiencing symptoms often or always in the 4 weeks before hospitalization were: 63.8% itching, 59.7% irritation, 46.1% burning/stinging, 39% sensitivity, 26% pain (from 10% in guttate psoriasis to 50% in arthropathic), 25.4% bleeding (17% pustular, 19% localized plaque, 36% palmoplantar), and 23.9% bothered by water (from 8.5% in the guttate form to 68% in palmoplantar). The prevalence of all symptoms was significantly higher in women and tended to increase with clinical severity. CONCLUSIONS: Our study provides evidence of the high frequency of a number of symptoms in different subgroups of psoriasis patients determined by their sociodemographic characteristics, clinical type and disease severity. Symptoms represent a serious disabling factor in patients affected by psoriasis, including those with low levels of psychological distress. Dermatologists should include symptoms in the evaluation of disease severity both in clinical practice and in clinical trials.

Factors associated with patient satisfaction with care among dermatological outpatients.

BACKGROUND: It has been shown that poor patient satisfaction can lead to poor adherence to treatment with consequently poor health outcomes. In order to improve the quality of care perceived by the patient and thus the health outcome, it is important to understand which are the main factors influencing patient satisfaction. OBJECTIVES: To examine factors associated with patient satisfaction with care among dermatological out-patients. METHODS: This longitudinal study is based on a sample of dermatology out-patients. The independent effects on patient's satisfaction of patient characteristics (sociodemographic characteristics, disease severity, quality of life) and of specific aspects of provided health care (the time the physician spent with patients, physician's interpersonal skills, etc.) were examined by multiple logistic regression. RESULTS: A total of 1389 out-patients were selected at random and invited to participate. Of the 722 patients who agreed to participate, 424 fulfilled the inclusion criteria and 396 of these patients (93.4%) completed the study. Overall satisfaction was reported by 60.0% of patients. The likelihood of overall satisfaction was found to be significantly and independently increased by the physician's ability to give explanations and to show empathy for the patient's condition, and by the older age of patients. The likelihood of satisfaction also increased with increasing disease severity, but decreased with symptom-related poor quality of life. The lowest level of satisfaction was found among patients whose symptom-related quality of life was worse than the clinical severity rated by the dermatologist. CONCLUSIONS: Improving the physician's interpersonal skills can increase patient satisfaction, which is likely to have a positive effect on treatment adherence and health outcomes. Dermatologists succeeded better in establishing a good relationship with clinically more severely affected patients than with patients who were clinically mildly affected despite their quality of life being impaired. Thus, the inclusion of a patient-rated quality of life can be a useful measure in dermatology, as it enables clinicians to perceive the patients' perception of their health status.

Prognostic value of anesthesia type for patients treated for cutaneous melanoma.

BACKGROUND: General anesthesia has been reported to compromise several cell-mediated immune functions. Hence it is plausible that anesthesia could affect the postoperative outcome of cancer patients. OBJECTIVE: To study the influence of the type of anesthesia on survival of 459 patients with localized cutaneous melanoma observed between 1980 and 1991. METHODS: Crude survival proportions were calculated by the methods of Kaplan and Meier. Cox proportional hazards regression analysis was used to estimate the effect on death rates of the type of anesthesia. RESULTS: The 5-year survival proportions were 81% for patients treated under local anesthesia, 71.9% for patients receiving halothane isoflurane or enflurane, and 88.4% for neuroleptanalgesia (P < .05). After multiple adjustment for other prognostic variables (tumor thickness, presence of ulceration, age, sex, cross-sectional profile), using patients treated under local anesthesia as a reference group, the relative risk for general anesthesia with volatile agents was 1.3 (95% CI, 0.84-2.10). CONCLUSION: The type of anesthesia does not seem to affect the survival of patients with cutaneous melanoma, when other prognostic factors are considered.

Stressful life events, social support, attachment security and alexithymia in vitiligo. A case-control study.

BACKGROUND: It has often been suggested that stress might trigger vitiligo. However, only one study supported this hypothesis, and no study explored the role of other personality or social factors. METHODS: Out-patients experiencing a recent onset or exacerbation of vitiligo (n = 31) were compared with out-patients with skin conditions in which psychosomatic factors are commonly were regarded as negligible (n = 116). Stressful events during the last 12 months were assessed with Paykel's Interview for Recent Life Events. Attachment style, alexithymia and social support were assessed with the 'Experiences in Close Relationships' questionnaire, the Toronto Alexithymia Scale (TAS-20), and the Multidimensional Scale of Perceived Social Support, respectively. RESULTS: Cases and controls did not differ regarding the total number of events and the number of undesirable, uncontrollable or major events. Three or more uncontrollable events had occurred more frequently among cases than controls. Perceived social support was lower in cases than in controls. Cases scored higher than controls on anxious attachment, tended towards higher scores on avoidant attachment and were classified more often as insecure. Cases scored higher than controls on the TAS-20 and were classified more often as alexithymic or borderline alexithymic. The occurrence of many uncontrollable events, alexithymia and anxious attachment were associated with vitiligo also in multiple logistic regression analysis. CONCLUSIONS: These findings suggest that vulnerability to vitiligo is not increased by stressful events, except for many uncontrollable events. Alexithymia, insecure attachment and poor social support appear to increase susceptibility to vitiligo, possibly through deficits in emotion regulation or reduced ability to cope effectively with stress.

Psychosomatic factors in first-onset alopecia areata.

Although the onset of alopecia areata has often been anecdotally linked with emotional stress, findings from the few controlled studies have not been univocal. The authors compared outpatients experiencing a recent onset of alopecia areata (N=21) with outpatients affected by skin conditions commonly believed as having a low psychosomatic component (N=102). Participants were administered Paykel's Interview for Recent Life Events, the Experiences in Close Relationships scale, the 20-item Toronto Alexithymia Scale, and the Multidimensional Scale of Perceived Social Support. Multiple logistic regression was used to control for age and gender. The total number of recent life events (last 12 months) was not different between the alopecia patients and the comparison subjects. Also, the alopecia patients and the comparison subjects did not differ in terms of the number of undesirable or major events. The comparison subjects even experienced a greater number of uncontrollable events. Alopecia areata tended to be associated with high avoidance in attachment relationships, high alexithymic characteristics, and poor social support. The results suggest that personality characteristics might modulate individual susceptibility to alopecia areata.