01_Impacto da Psoríase

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Psoríase: Impacto da Doença
Psoriasis: Scope of the Problem
Section: 1
Psoríase: Impacto da Doença
	A psoríase é uma doença crônica, heterogênea cuja patogênese não está claramente definida, embora fatores genéticos, ambientais e imunológicos desempenhem papéis importantes1
	A psoríase afeta 1% a 6% das pessoas no mundo todo2-3
	A psoríase interfere com as funções diárias, causa estresse psicológico, e afeta as relações sociais4
	A psoríase só é ultrapassada pela insuficiência cardíaca congestiva em incapacidade física descrita pelo paciente no SF-364 
	Os pacientes com psoríase têm maior incapacidade do que aqueles que têm hipertensão, diabetes MI, depressão e artrite4
1 Lebwohl M. Lancet 2003.
2 Raychaudhuri SP, Farber EM. JEADV 2001.
3 Granstein R. N Engl J Med 2001.
4 Rapp S et al. J Am Acad Derm 1999.
Psoriasis: Scope of the Problem
Psoriasis varies in severity depending on inheritance and environmental factors. Some patients have mild disease with isolated scaling erythematous plaques on the elbows, knees, or scalp, whereas others can have up to 100% of their cutaneous surface affected.1 Psoriasis affects approximately 1% to 6% of persons throughout the world. 2-3 The comparison of psoriasis with other chronic medical conditions suggest that psoriasis is typically not life threatening; however psoriasis can have a significant adverse effect on quality of life. 
References
	Lebwohl M. Psoriasis. Lancet 2003;361:1197-1204.
	Raychaudhuri SP, Farber EM. The Prevalence of Psoriasis in the World. JEADV 2002;15:20-23.
	Granstein R. New Treatments for Psoriasis. N Engl J Med. 2001;345,4: 284-287.
	Rapp SR. et al. Psoriasis Causes as Much Disability as Other Major Medical Diseases. J Am Acad Dermatol 1999;41:401-407.
Psoríase: Impacto da Doença
	A psoríase é caracterizada pela proliferação da epidermis, o sistema imunológico tem um papel prominente no desenvolvimento da doença
	Homens e mulheres são igualmente afetados
	Psoríase do tipo placa é a forma mais comum, que ocorre em mais de 80% dos casos
	Os pacientes com doença mais grave ou antiga podem ter comprometimento da unha
	Entre 5% e 42% dos pacientes com psoríase têm artrite psoriática
Lebwohl M. Lancet 2003; 361:1197-1204.
Psoriasis: Scope of the Problem
Psoriasis is characterized by proliferation of the epidermis. A widely accepted concept is that psoriasis is primarily a disorder that involves the proliferation of keratinocytes, with secondary inflammation. Supporters of this concept have noted defects in cytokine expression, intracellular signaling, as well as abnormalities of keratinocytes in psoriatic lesions.. Another concept is that psoriasis is primarily a disorder of inflammatory cells and that the striking proliferation of keratinocytes is a secondary phenomenon. This hypothesis is supported by the evidence that immune mechanism play a part is psoriasis.
Psoriasis tends to be more frequent at higher latitudes than lower latitudes and in more caucasians than in other races. Prevalence of psoriasis is equal in men and women. Plaque-type psoriasis is the most common form of the disease, occurring in more than 80% of cases. Nail changes eventually occur in most patients. Patients with more severe or long-standing disease are more likely to have nail changes than those with less severe or recent-onset disease, and such changes are associated with scalp involvement, periungual involvement, and psoriatic arthritis.
Reference
Lebwohl M. Psoriasis. Lancet 2003;361:1197-1204.
O que é Psoríase?
	A psoríase é considerada um distúrbio de hiperproliferação de ceratinócitos na epiderme secundário à ativação de linfócitos na derme1,2
	Há evidência crescente de que as células T ativadas sejam os principais moduladores na patogênese de psoríase
	Níveis de elevados de linfócitos T ativados estão presentes nas placas psoriáticas e sangue dos pacientes com psoríase
	Há um número elevado de sub-grupos de células T efetoras que foram encontrados na epiderme e derme de placas psoriáticas
1 Granstein R. N Engl J Med 2001;345,4:284-287.
2 Kormeili T et al. B J Dermatol 2004:151:3-15.
What is Psoriasis?
Psoriasis is a chronic, incurable inflammatory skin disorder. Current hypotheses regarding the etiology of psoriasis involve cell-mediated immune responses and cytokine expression that invoke an inflammatory response leading to psoriatic plaques. There is direct evidence of the involvement of T cells in psoriasis. 
References
1. Granstein R. New Treatments for Psoriasis. N Engl J Med 2001;345,4:284-287.
2. Kormeili T et al. Psoriasis: Immunopathogenesis and Evolving Immunomodulators and Systemic Therapies: US Experiences. B J Dermatol 2004:151:3-15.
Psoríase: 
A Doença de Célula T Mais Prevalente
	 A psoríase é a doença inflamatória mediada por célula T mais prevalente no homem
 
	 A patogênese de psoríase é ligada a:
	Ativação de vários tipos de leucócitos que controlam a imunidade celular
	O processo inflamatório dependente da célula T na pele que acelera o crescimento de células da epiderme e vasculares em lesões psoriáticas
Prevalência de Psoríase 
Raychaudhuri SP et al. JEADV 2001;15:16-17.
Prevalence of Psoriasis
The prevalence of psoriasis has been reported at a rate of 6.5% in Germany, 5.5% in Ireland, 4.8% in Scotland, 3.7% in Spain, 2.3% in Sweden, 4.8% in Norway, 2.0% in Russia, 2.2%-4.6% in the USA, and 4.7% in Canada.
Reference
Raychaudhuri SP et al. The Prevalence of Psoriasis in the World. JEADV 2001;15:16-17.
O que Define a Psoríase Leve, Moderada, 
Grave?
	A categorização de psoríase é qualitativa
	Baseada na atividade da doença, questões psico-sociais, resposta à terapia
	Psoríase Leve 
	Tipicamente definida com base no comprometimento limidado da BSA 
	Pode necessitar de fototerapia se a resposta ao tratamento tópico não for satisfatória 
	Psoríase moderada a grave 
	Generalmente definida por comprometimento de BSA > 5% 
	Pode envolver as palmas, solas, cabeça, pescoço, genitália
Callen P et al. J Am Acad Dermatol 2003;49:897-899.
What Defines Mild, Moderate, Severe Psoriasis?
Severity is a qualitative decision that hinges on measures of disease activity, resistance to prior therapy, and psychosocial considerations. Defining disease severity is generally based on the overall judgment of the treating physician based on the patient’s history, examination of the skin lesions, and consideration of such factors as the: disease location, age of the patient, response to previous therapies, economics, and co-morbidiites.
Reference
Callen JP et al. AAD Consensus Statement on Psoriasis Therapies. J Am Acad Dermatol 2003;897-899.
Definição da Qualidade de Vida de Psoríase
	Psoríase leve:
	Generalmente BSA <5% 
	A doença não altera a qualidade de vida dos pacientes
	Psoríase moderada
	Comprometimento da BSA de 2-20% 
	A doença altera a qualidade de vida dos pacientes
	Psoríase Grave
	Generalmente BSA significativamente >10% 
	A doença altera a qualidade de vida do paciente
	Os pacientes que quiserem aceitar os efeitos colaterais que alteram suas vidas conseguem melhora 
Krueger G et al. J Am Acad Dermatol 2000;43:281-285.
Quality of Life Definition of Psoriasis
Body surface area (BSA) is usually used to define severity for clinical trials. It is not optimal for defining psoriasis severity because there are some patients with low BSA involvment who have very severe psoriasis and some patients with high BSA involvment who have mild involvement.
The definitions of mild and moderate to severe psoriasis provided on this slide define psoriasis based on the patient’s perception (the varying ability of patients to accept side effects, the inconvenience of topical and ultraviolet light-based treatments, costs, efficacy/toxicity of current treatments, and the prescribing habits of physicians). 
Reference
Krueger GG. et al Two Considerations for Patients with Psoriasis and Their Clinicians: What Defines Mild, Moderate, and Severe Psoriasis? What Consitutes a ClinicallySignificant Improvment When Treating Psoriasis? J Am Acad Dermatol 2000;43:281-285.
Psoríase: Fatores de Risco
	Os fatores de risco que podem aumentar o risco de psoríase incluem:
	estresse, uso de álcool, tabagismo e obesidade
	De acordo com vários relatos, o estresse pode afetar a psoríase de forma adversa em 37% a 80% dos pacientes
	Há maior risco de psoríase nos fumantes vs. não-fumantes
	Raychaudhuri e cols. (n=104) observaram que o estresse, uso de álcool, tabagismo, obesidade e falta de exercícios têm efeitos adversos sobre a psoríase
	A compreensão dos fatores de risco é essencial para proporcionar um tratamento abrangente
Raychaudhuri SP, Gross J. Cutis 2000;66:348-352.
Psoriasis: Risk Factors
Reports in the literature suggest that factors including emotional stress, alcohol use, smoking, and obesity have deleterious effects and increase morbidity of psoriasis. 
In a study of patients with psoriasis carried out by Raychaudhuri et al. (n=104), results suggest that emotional stress, alcohol use, smoking, obesity, and lack of exercise have adversely affect psoriasis. The investigators identified a positive correlation between stress and the percentage of body surface involvement. 
In patients who had more than 10% skin surface involvement, 45% were stressed, whereas, 32.5% of patients with less than 5% body surface involvement were stressed. In those patients who experienced remission, two-thirds were low alcohol users. Also, among patients who experienced remission, 78% were nonsmokers. Interestingly, overweight was found to be a risk factor. The greater the body surface involvement the more likely the patient was to be overweight. In those patients who had more than 10% body surface involvement 71.4% weighed above their recommended body weight.
Reference
Raychaudhuri SP, Gross J. Psoriasis Risk Factors: Role of Lifestyle Practices.Cutis 2000;66:348-352.
Morbidade Psiquiátrica na Psoríase
	A psoríase pode ter impacto emocional substancial nos pacientes não necessariamente relacionado à extensão do comprometimento da pele
	A psoríase está associada a uma variedade de problemas psicológicos:
	Baixa auto-estima
	Disfunção sexual 
	Ansiedade 
	Depressão
	Desejos suicidas 
Russo P et al. Australian Journal of Dermatology 2004;45,3:155-159.
Psychiatric Morbidity in Psoriasis
Psoriasis is associated with a variety of psychological problems, including poor self-esteem, sexual dysfunction, anxiety, depression and suicidal ideation. The clinical degree of severity may not reflect the degree of emotional impact of the disease.
Reference
Russo PA et al. Psychiatric Morbidity in Psoriasis: A Review. Australian J of Dermatol 2004;45:155-161.
Relação Entre Estresse 
& Psoríase
	Com base em uma extensão revisão do Medline (1966-2002) os estudos de prevalência disponíveis apresentam de forma uniforme altas taxas de psicopatologia nos pacientes com psoríase 
	Em um estudo realizado por Fortune e cols. aproximadamente 60% dos pacientes acreditavam que o início da sua psoríase foi causado por estresse 
	A maioria dos estudos controlados identificou uma associação positiva entre estresse e psoríase 
Russo P et al. Australian Journal of Dermatology 2004;45,3:155-161.
Relationship Between Stress & Psoriasis
The role of stress as a trigger for exacerbation of psoriasis continues to be debated. A recent literature review conducted by Russo et al. reviewed controlled studies that examined the influence of stress on psoriasis. Based on the literature search (1966-2002), the reviewers identified a positive association between stress and psoriasis. 
Reference
Russo PA et al. Psychiatric Morbidity in Psoriasis: A Review. Australian J of Dermatol 2004;45:155-161.
O Estresse é Fator de Risco para a Gravidade de Psoríaseis 
Raychaudhuri SP, Gross J. Cutis 2000;66:348-352.
Stress is a Risk Factor for Severity of Psoriasis 
In a study conducted by Raychaudhuri et al. (n=104), stress correlated with a higher percentage of body surface area involvement.
Reference
Raychaudhuri SP, Gross J. Psoriasis Risk Factors: Role of Lifestyle Practices.Cutis 2000;66:348-352.
Efeitos Psicológicos da Psoríase
Russo P et al. Australian Journal of Dermatology 2004;45,3:155-161.
Jewett S et al. Soc. Sc: Med 1985;20:425-429.
Psychological Effects of Psoriasis
In a study of patients with psoriasis conducted by Jewett et al., 89% felt shame and embarrassment over their appearance, 58% suffered from anxiety, 42% suffered lack of confidence, and 24% experienced depressive symptoms.
Reference
Russo PA et al. Psychiatric Morbidity in Psoriasis: A Review. Australian J of Dermatol 2004;45:155-161.
 
Psoríase e Abuso de Substância
	Nos pacientes com psoríase, o abuso de substâncias é um fator de risco independente para suicídio 
	Gupta e cols. observaram que a prevalência de alcoolismo nos pacientes com psoríase era 18% em comparação com 2% nos pacientes com outras condições dermatológicas
	Ingestão de >80 g de álcool por dia pode afetar de forma negativa o prurido e estar associada a distúrbios do sono
	O uso de álcool, tabagismo, uso de calmantes, remédios para dormir e anti-depressivos prevê de forma significativa a gravidade da doença e o comprometimento da qualidade de vida relacionada à psoríase 
Russo P et al. Australian Journal of Dermatology 2004;45,3:155-159.
Psoriasis and Substance Abuse
Substance abuse is an independent risk factor for suicide. Gupta et al. found the prevalence of alcoholism among patients with psoriasis was 18% as compared with 2% among patients with other dermatological conditions. Zacharie et al. reported that alcohol use, cigarette smoking, use of tranquilizers, sleeping pills and antidepressants significantly predicted both disease severity and impairment of psoriasis-related quality of life.
Reference
Russo PA et al. Psychiatric Morbidity in Psoriasis: A Review. Australian J of Dermatol 2004;45:155-161.
Excesso de Mortalidade Devido ao Álcool 
& Fumo em Pacientes com Psoríase
Poikolainen K et al. Arch Dermatol 1999;135: 1490-1493.
	Principais Causas de Morte nos Pacientes com Psoríase
	Homens	Mulheres 
	Causas de Morte 	No. Observado
de Mortes	SMR	No. Observado
de Mortes	SMR
	Relacionada ao álcool	202	2,14	89	1,47
	Diretamente 	94	4,46	13	5,60
	Indiretamente 	108	1,47	76	1,31
	Relacionada ao Fumo 	594	1,44	400	1,61
	Ambos 	13	1,92	8	2,52
	Outras 	1,72
	Todas 	1,62
Excess Mortality Due to Alcohol & Smoking in Inpatients with Psoriasis
In this Finnish cohort study of psoriasis patients, mortality was followed for 22 years by examining the Cause-of-Death Register. Patients included in the cohort were 3132 men and 2555 women admitted to inpatient treatment with psoriasis as the principal diagnosis. The investigators identified an increase in deaths due to alcohol- and smoking-related causes. The highest death rates were alcohol-related causes. Among men, these causes included alcohol-related psychosis, liver disease, and alcohol dependence; among women, liver disease. Some of the smoking-related causes (e.g., lung and bladder cancer) were also found to be elevated, but to a lesser degree. The findings of this large cohort study strongly support the view that alcohol intake and smoking increase the mortality among patients with psoriasis. 
Reference
Poikolainen K et al. Excess Mortality Related to Alcohol and Smoking Among Hospital-Treated Patients with Psoriasis. Arch Dermatol 1999;135: 1490-1493.
Depressão & Suicídio 
na Psoríase
	A psoríase tem um alto grau de morbidade psiquiátrica
	Ginsburg e cols. (N=100) observaram que 50% dos pacientes se identificaram com a frase “Sinto-me totalmente só com minha psoríase”
	As condições diagnosticadas com maior frequência são distúrbios depressivos e de ansiedade
	O prurido, seguido por desfiguração são os preditores mais significativos de depressão 
	O desejo de suicídio é um sério problema
	As taxas são o dobro das observadas para a populaçãoem geral
Russo P et al. Australian J. Dermatology 2004;45,3:155-159.
Depression and Suicidality in Psoriasis
Depression and anxiety disorders affect a significant proportion of patients with psoriasis. Ginsberg et al. (n=100) patients found that 51% of patients with psoriasis identified with the statement: “I feel totally alone with my psoriasis.” Forty-seven percent said that when my skin is badly broken out, there are times when I feel life is not worth living. In a study conducted by Gupta et al. (n=77), the most significant predictor of depression was pruritis, followed by the degree of disfigurement.
Suicidal ideation is a serious problem among patients with severe psoriasis. Gupta et al. found that the rate of suicidal ideation was 2.5% consistent with figures seen with other chronic illness. However, in a second study Gupta et al found that the rate was greater than two-fold that found in the general population.
Substance abuse is an independent risk factor for suicide. Gupta et al. found that the prevalence of alcoholism among patients with psoriasis was 18% compared to 2% among patients with other dermatological conditions. Independently, Zacharie et al. reported that alcohol use, cigarette smoking, use of tranquilizers, sleeping pills and antidepressants significantly predicted both disease severity and impairment of psoriasis-related quality of life.
Reference
Russo PA et al. Psychiatric Morbidity in Psoriasis: A Review. Australian J of Dermatol 2004;45:155-161.
Obesidade é um Fator de Risco para Aumento da Gravidade de Psoríase 
Raychaudhuri SP, Gross J. Cutis 2000;66:348-352.
Obesity is a Risk Factor for Increased Severity of Psoriasis
In a study conducted by Raychaudhuri et al. (n=104), psoriasis was more extensive in patients who were overweight.
Reference
Raychaudhuri SP, Gross J. Psoriasis Risk Factors: Role of Lifestyle Practices.Cutis 2000;66:348-352.
Aumento do Risco de Mortalidade Cardiovascular 
em Pacientes Hospitalizados com Psoríase
Mallbris L et al. European Journal of Epidemiology 2004;19:225-230. 
	Variáveis 	 Obs Exp SMR	Valor de P 
	Total 	1529	1007	1,52
	Mulheres 	655	456	1,44
	Homens	874	551	1,59	0,06
	Número de Internações
	1 	1529	1007	1,52
	2	851	501	1,70
	3 	610	334	1,82	<0,001
Increased Risk of Cardiovascular Mortality in Patients with Psoriasis
In this Swedish registry study of psoriasis patients, the investigators found no increase in cardiovascular mortality among outpatients with psoriasis compared to the general population. Interestingly, the overall risk among patients who were hospitalized at least once due to their psoriasis was increased by 50%. The excess risk increased with increasing number of hospitalizations (p<0.001). Cardiovascular mortality was higher among those admitted at younger ages (p<0.001); SMR 2.62. The investigators concluded that repeated admissions, and early age at first admission, are associated with increased risk for cardiovascular death.
Reference
Mallbris L et al. Increased Risk For Cardiovascular Mortality in Psoriasis Inpatients But Not In Outpatients. European Journal of Epidemiology 2004;19:225-230. 
Comparação Entre os Adultos Saudáveis & Pacientes Com Psoríase & Outras Doenças Crônicas
55
47
45
45
44
43
43
42
42
41
35
30
35
40
45
50
55
60
Adultos saudáveis
Dermatite
Câncer
Depressão
Hipertensão
Artrite
Infarto do Miocárdio
Doença pulmonar crônica
Diabete Tipo 2
Psoríase
Insuficiência cardíaca congestiva
Rapp SR et al. J Am Acad Dermatol. 1999;41:401.
Pontuação Resumida do Componente Físico do SF-36
Pontuação Resumida do Componente Físico
Comparison Between Healthy Adults & Patients With Psoriasis & Other Chronic Diseases
To compare the impact psoriasis has on HRQL with the impact other chronic conditions have on it, the standardized physical component score completed by 317 patients was compared with healthy adults and patients having other chronic diseases. The chart above shows the mean scores on the Physical Component Summary Score (PCS) ranged from a high of 55 for healthy adults to a low of 35 for patients with congestive heart failure.
Reference
Rapp SR. et al. Psoriasis Causes as Much Disability as Other Major Medical Diseases. J Am Acad Dermatol 1999;41:401-407.
Comparação Entre os Adultos Saudáveis & Pacientes Com Psoríase & Outras Doenças Crônicas
53
52
52
52
50
49
49
46
46
45
35
30
35
40
45
50
55
Adultos saudáveis
Hipertensão
Diabete tipo 2
Infarto do Miocárdio
Insuficiência Cardíaca congestiva
Câncer
Artrite
Dermatite
Psoríase
Doença pulmonar crônica
Depressão
Pontuação Resumida do Componente Mental do SF-36
Pontuação Resumida do Componente Mental
Rapp SR et al. J Am Acad Dermatol. 1999;41:401.
Comparison Between Healthy Adults and Patients with Psoriasis and Other Chronic Diseases
This slide presents the mean scores on the Mental Component Summary Score for 317 patients with psoriasis, healthy adults, and patients with other chronic diseases. The Mental Component Summary Score (MCS) scores ranged from 53 for healthy adults to 35 for patients with depression.
Reference
Rapp SR. et al. Psoriasis Causes as Much Disability as Other Major Medical Diseases. J Am Acad Dermatol 1999;41:401-407.
38,0%
28,6%
40,0%
71,4%
62,0%
60.0%
0
10
20
30
40
50
60
70
80
<5%5%-10%>10%
Porcentagem de Comprometimento
da Pele
Porcentagem de Pacientes
Pacientes magros
Pacientes com Sobrepeso
4,7
4,6
2,0
4,8
2,3
3,7
4,8
5,5
6,5
012345678910
Canada
EUA
Russia
NoruegaSuécia 
Espanha
Escócia
Irlanda
Alemanha
Porcentagem da População 
89%
62%
42%
24%
0
10
20
30
40
50
60
70
80
90
100
VergonhaAnsiedadeFalta de
Confiança
Depressão 
Porcentagem de Pacientes
45,2%
38,1%
32,5%
67,5%
61,9%
54.8%
0
10
20
30
40
50
60
70
80
<5%5%-10%>10%
Porcentagem de Comprometimento
da Pele
Porcentagem de Pacientes
Pacientes Estresse
Pacientes Não
Estressados