assessment of quality of life in patients with psoriasis: a study from serbia

Report

Assessment of quality of life in patients with psoriasis: a

study from Serbia

Danijela Mil�ci�c1, MD, MSc, Slavenka Jankovi�c2, MD, PhD, Sonja Vesi�c1, MD, PhD,Mirjana Milinkovi�c1, MD, PhD, and Janko Jankovi�c3, MD, PhD

1Institute of Dermatovenereology, Clinical

Center of Serbia and Faculty of Medicine

Institutes of 2 Epidemiology and 3 Social

Medicine, Faculty of Medicine, University of

Belgrade, Belgrade, Serbia

Correspondence

Danijela Mil�ci�c, MD, MSC

Clinical Center of Serbia

Institute of Dermatovenereology

Pasterova 2

11000 Belgrade

Serbia

E-mail: [email protected]

Conflicts of interest: None.

doi: 10.1111/ijd.12391

Abstract

Background Psoriasis has a substantial impact on patients’ quality of life.

Objectives The aims of this study were to assess the impact of the clinical severity of

psoriasis on patients’ quality of life and to determine the effects of psoriasis-related stress

on patients’ everyday life.

Methods The cross-sectional study was conducted at the Institute of Dermatovenereology,

Clinical Center of Serbia, Belgrade. The study included 201 patients (124 men and 77

women), aged 18–70 with a diagnosis of psoriasis, hospitalized or treated as outpatients

during 2009. For the assessment of patients’ quality of life, the psoriasis disability index

(PDI) was used. The stress related to psoriasis was measured with the psoriasis life stress

inventory (PLSI) and disease severity with the psoriasis area and severity index (PASI).

Results We found moderate correlation between PLSI and all PDI subscales and overall

score (correlation coefficients ranged from 0.334 to 0.521). The correlation between PASI

and PDI subscales was weak, while we failed to find any significant correlation between

PASI and the PLSI. The results of multiple regression analysis indicated that stress, more

severe disease, and lower educational level are significant determining factors of a poorer

quality of life in patients with psoriasis.

Conclusion Our results support the importance of assessing the quality of life in psoriasis

and effects of stress in patients’ adjustment to their condition and may have important

implications for a psychological stress management approach in the clinical management

of psoriasis.

Introduction

Psoriasis is an immune-mediated inflammatory skindisease with complex pathogenesis. It is a chronic, geneti-cally determined disease, characterized by different clini-cal manifestations and unpredictable course.Generally psoriasis is not a life-threatening disease but

has a profound negative impact on a patient’s quality oflife.1–3 Although psoriasis affects approximately 2% ofthe world’s population,4 very few studies examined qual-ity of life in patients with psoriasis in southeastern Euro-pean.5,6 World-wide, it is well known that patients withpsoriasis have difficulties in their daily activities, andoccupational and sexual functioning.7–9 In addition,patients with psoriasis, significantly more frequently thanthe general population, have various psychiatric disorders,such as depression, anxiety, social isolation, even suicidalideation.3,10–12 Owing to the visibility of skin lesions,patients may feel humiliated and embarrassed, and thechronic and recurring nature of the disease makes them

feel helpless.13–15 High levels of stress may be associatedwith worsening of the disease and lack of appropriatetherapeutic response.16 Negative impact of psoriasis on apatient’s quality of life has been demonstrated in a num-ber of studies, and its correlation with the demographicand clinical disease characteristics varies.5,17,18

Researchers have indicated that 30–40% of patientswith psoriasis suffer significant psychological distressrelated to their disease.19

The aims of this study were to assess the impact of psoriasis(especially its clinical severity) on patients’ quality of life,and to investigate the effects of perceptions of psoriasis-related stress on areas of disability in everyday life.

Methods

Patients

A cross-sectional study was carried out at the Institute of

Dermatovenereology, Clinical Center of Serbia (Belgrade),

during 2009. The study group consisted of 201 consecutive

ª 2014 The International Society of Dermatology International Journal of Dermatology 2014

1

patients with psoriasis, of both sexes, aged 18–70 years, with

duration of the disease of at least three months before the

examination. All patients were in the exacerbation stage of

psoriasis. The majority of them (71%) required hospital

admission while ambulatory patients accounted for a smaller

part of the study group (29%). None of the patients has been

treated with systemic therapy before examination.

The study protocol was approved by the Ethics Committee of

the Clinical Center of Serbia, Belgrade, and written informed

consent was obtained from all participants.

Instruments

A short standardized form was used to collect data regarding

age, sex, education, duration of psoriasis, age at onset, and

family history of psoriasis.

Diagnosis of psoriasis was confirmed by experienced

dermatologists.

The psoriasis area and severity index (PASI) was used for

the assessment of the disease severity.20 The PASI score is

obtained as a result of evaluation of erythema, infiltration,

desquamation, and area of the skin involved by psoriasis. It can

vary from 0 (the lowest score) to 72 (the highest score) with

higher scores indicating greater severity. In our study, mild

psoriasis was classified as a PASI <12, moderate psoriasis

between 12 and 25, and severe psoriasis as >25. To date, no

consensus has been reached on the cut-off levels for the PASI.

The reason that we used the above-mentioned cut-off values is

that our study was carried out in the large tertiary care hospital

(Institute of Dermatology, Clinical Center of Serbia) where

serious skin conditions and illnesses are often cared for. If we

used lower cut-off values as in most studies, the majority of our

patients would be in one group – the group of patients with

severe psoriasis – without a possibility for comparison.

To evaluate the impact of psoriasis on the patients’ quality of

life, we used the psoriasis disability index (PDI), a 15-item scale

related to daily activities, work or school, personal relationships,

leisure, and treatment effects.21 All the questions referred to

events that had taken place in the preceding four weeks. The

answers were scored from 0 to 3 (0, “not at all”; 1, “a little”; 2,

“a lot”; 3,“very much”), producing a range of total PDI score

from 0 to 45. The higher the score, the more quality of life is

impaired.

The 15-item version of the psoriasis life stress inventory

(PLSI) was used to measure stress associated with having to

cope with everyday events in living with psoriasis.22 For each

item, patients were asked to rate the level of stress

experienced over the previous four weeks on a four-point scale,

from “not at all” to “a great deal”. According to the results of the

total PLSI score (ranged from 0 to 45), patients were classified

into two groups: high stress reactors (patients who reacted

significantly to the stress associated with having psoriasis

[score of ≥10]), and low stress reactors (patients who were not

significantly affected by psoriasis-related stress [score of <10]).

The validated and cross-culturally adapted Serbian versions of

the used questionnaires showed good internal reliability across

scales (Cronbach’ s alpha was 0.84 for PDI and 0.78 for PLSI).

Statistical analysis

Categorical variables were expressed as counts and

percentages. Continuous variables were presented as

mean � standard deviation (SD). Mean scores of each

instrument were calculated for different subgroups studied (mild,

moderate, and severe psoriasis), and differences between them

were assessed by the t-test and ANOVA. To verify how PASI,

PDI, and PLSI scores correlated between themselves, we used

the Pearson’s (r) correlation coefficient.

A multiple linear regression analysis was carried out to

examine the strength of the relationship between demographic

(sex, education), clinical variables (clinical type, duration of the

disease and its severity assessed by PASI), psoriasis-related

stress (PLSI score), and quality of life (overall PDI score as the

dependent variable). Age and age of onset were not introduced

in the model because of collinearity with the variable “duration”.

A two-tailed probability value of 0.05 or less was considered

significant. All statistical analyses were performed with the

Statistical Package for the Social Sciences, version 16.0 for

Windows (SPSS Inc., Chicago, IL, USA).

Results

The sociodemographic and clinical characteristics of 201patients (124 men and 77 women) are shown in Table 1.The majority of patients had moderate (41.3%) to severe(27.4%) psoriasis, while almost one-third of patients(31.3%) had mild psoriasis. The most frequent form ofpsoriasis was plaque psoriasis, followed by guttate anderythrodermic psoriasis.There were no sex differences in scores for any of the

quality of life measures.Patients with a family history of psoriasis were younger

and had a longer duration of disease, an earlier age atonset, and experienced a more severe disease than thosepatients who had no family members with psoriasis(Table 2). No significant correlation was found betweenfamily history of psoriasis and quality of life, while inten-sity of stress was significantly higher in patients whoreported a family history.The mean PDI score for the whole sample was 19.3

(�9.7). The mean scores of the PDI and its domains inthree groups of patients formed according to their PASIscores are presented in Table 3.The impact of psoriasis on quality of life, i.e., on daily

activities, employment, and leisure activities, was signifi-cantly higher in patients with moderate and severe psoriasisin comparison with those with a mild form of the disease.Statistically significant differences between groups were

International Journal of Dermatology 2014 ª 2014 The International Society of Dermatology

Report Quality of life in psoriasis Mil�ci�c et al.2

not found for personal relationships and treatment relatedeffects.The relationship between quality of life measures (PDI,

PLSI) and PASI, expressed by Pearson correlation coeffi-cients, is shown on Table 4.We found moderate correlation between PLSI and all

PDI subscales and overall score (correlation coefficientsranged from 0.334 to 0.521). The correlation betweenclinical severity of psoriasis (PASI) and PDI subscaleswas weak, although statistically significant (correlation

coefficients were between 0.163 and 0.321), while wefailed to find any significant correlation between PASI andthe PLSI.Patients whose distribution on the PLSI classified them

as highly reactive to stress associated with psoriasis (score≥10) in comparison with low stress reactive patients(score <10) who perceived themselves as more disabled inall areas of everyday life as assessed by the PDI (Table 5).These differences were not found for clinical severity ofthe psoriasis, as these two stress groups did not differ onthe PASI.To investigate the relationship between demographic

and clinical variables and psoriasis-related stress as inde-pendent variables, and perceived disability in everyday life(total PDI score) as a dependent variable, a multipleregression analysis was performed. Our findings suggestthat stress, more severe disease, and lower educationallevel are significant determining factors of a poorer qual-ity of life in patients with psoriasis (Table 6).

Discussion

It is well known that health-related quality of life isimpaired in patients with psoriasis.3,5,15 Patients withpsoriasis have a reduction in their quality of life similarto or worse than patients with other chronic diseases,such as ischemic heart disease and diabetes.23 Living withpsoriasis and its treatments may affect patients’ physical,psychological, and social functioning, and well-being.24

The results of the current study indicate that psoriasishas a significant negative impact on patients’ quality of life.We also found that correlation between clinically

assessed disease severity and quality of life of patientswith psoriasis was generally weak (correlation coefficientsranged from 0.163 to 0.321). Literature data on the rela-tionship between clinically assessed disease severity andquality of life were not entirely consistent. More severepsoriasis was associated with lower levels of quality oflife in a number of studies.17,21,25,26 However, the associ-ation between clinically assessed severity and quality oflife in several other studies was generally weak.24

In our study, patients with moderate and severe psoria-sis more frequently reported problems with bathing(having to take more baths than usual) and clothing (hav-ing to wear special clothes and/or having to change orwash clothes more often) than patients with mild disease,while there were no differences between groups in homemanagement (problems with work around the house orgarden) and hairdressing. Performance of professionalactivities, absenteeism, and unemployment were signifi-cantly correlated with severity of the disease. In the areaof personal relationships, sexual functioning, and treat-ment-related problems, the correlation with the severity

Table 2 Scores for demographic, clinical and quality of lifevariables in patients with psoriasis as a function of theirfamily history of psoriasis (mean � SD)

Variable

Family history of psoriasis

P valueaNo (n = 140) Yes (n = 61)

Age 52.41 � 12.69 47.57 � 13.62 0.016

Duration of psoriasis 3.73 � 2.11 4.57 � 1.69 0.000

Age at onset 48.69 � 12.78 43.00 � 13.39 0.005

PASI 19.13 � 13.29 22.70 � 15.75 0.030

PDI 19.04 � 9.59 19.82 � 10.06 NS

PLSI 14.84 � 11.05 18.46 � 10.54 0.032

NS, not significant; PASI, psoriasis area and severity index;PDI, psoriasis disability index; PLSI, psoriasis life stressinventory.at-test.

Table 1 Sociodemographic and clinical characteristics of thepatients in the study population

Characteristic

Sex, n (%)

Male 124 (61.7)

Female 77 (38.3)

Education, n (%)

Elementary school 55 (27.4)

Secondary school 112 (55.7)

Higher school 15 (7.5)

University degree 19 (9.5)

Age at inclusion, years (mean � SD) 50.79 � 13.26

Duration of disease, years (mean � SD) 3.99 � 2.03

Age at the onset of disease, years (mean � SD) 46.96 � 13.20

Family history, n (%)

Yes 61 (30.3)

No 140 (69.7)

Clinical type of the disease, n (%)

Plaque psoriasis 94 (46.8)

Guttate psoriasis 71 (35.3)

Erythrodermic psoriasis 26 (12.9)

Pustular psoriasis of the palms and soles 10 (5.0)

Psoriasis area and severity index (mean � SD) 20.2 � 14.1

Mild < 12, n (%) 63 (31.3)

Moderate 12–25, n (%) 83 (41.3)

Severe > 25, n (%) 55 (27.4)


Mil�ci�c et al. Quality of life in psoriasis Report 3

of the disease was poor. Regardless, our results confirmedthat the severity of the disease correlates with impairmentof quality of life of patients with psoriasis.According to our results, higher education level of

patients with psoriasis was associated with better qualityof life. It is known that education empowers individualsby increasing their knowledge and their cognitive, social,and emotional skills. As such, education can help patientsto manage their disease better.27

The family history of psoriasis in our study, similar tothe one conducted by Fortune et al.28 did not significantlyaffect a patient’s quality of life, but the presence of psori-asis within the family was associated with a more severeform of disease, its earlier onset, and higher level of psori-asis-related stress. We also did not find any significantassociation between age, sex, clinical type or duration ofthe disease, and quality of life.We found that stress from anticipating other people’s

reactions to their psoriasis contributed more to disabilityin everyday life than any other demographic or clinicalvariable investigated. Patients whose distribution of scoreson the PLSI classified them as reactive to stress associatedwith psoriasis perceived themselves as more disabled in

Table 4 Pearson correlation coefficients for relations between PDI, PLSI, and PASI

Daily

activities Employment

Personal

relationships

Leisure

activities

Treatment

effects PDI (total score) PLSI

Employment 0.703**

Personal relationships 0.467** 0.532**

Leisure 0.543** 0.571** 0.672**

Treatment 0.430** 0.362** 0.406** 0.519**

PLSI 0.462** 0.425** 0.334** 0.445** 0.340** 0.521*

PASI 0.206** 0.321** 0.172* 0.250** 0.163* 0.288** 0.119

PASI, psoriasis area and severity index; PDI, psoriasis disability index; PLSI, psoriasis life stress inventory.*P < 0.05; **P < 0.001.

Table 5 Domains of disability: PDI and clinical severity forlow and high stress reactive patients (mean � SD)

Domains of PDI

Low stress

reactive

High stress

reactive

P valuean = 62 n = 139

Daily activities 6.19 � 3.46 8.72 � 3.23 0.000

Employment 2.58 � 2.49 4.23 � 2.33 0.000

Personal relationships 1.31 � 1.51 2.19 � 1.78 0.001

Leisure activities 2.89 � 3.09 5.22 � 3.05 0.000

Treatment 0.74 � 0.90 1.40 � 1.00 0.000

Total PDI 13.71 � 9.7 21.76 � 8.66 0.000

PASI 18.75 � 16.65 20.87 � 12.87 NS

NS, not significant; PASI, psoriasis area and severity index;PDI, psoriasis disability index.at-test.

Table 6 Results of the multiple linear regression analysis onthe psoriasis disability index

Variable Ba P value

PLSI 0.438 < 0.001

PASI 0.154 0.001

Education �1.399 0.025

PASI, psoriasis area and severity index; PLSI, psoriasis lifestress inventory.aUnstandardized regression coefficient.

Table 3 Comparison of PDI scores for patients with mild, moderate, and severe psoriasis (mean � SD)

QoL indices

PASI < 12 PASI (12–25) PASI > 25

P valuean = 63 n = 83 n = 55

Daily activities 6.52 � 3.45 8.48 � 3.32 8.74 � 3.37 0.000

Employment 2.60 � 2.20 3.96 � 2.43 4.64 � 2.47 0.000

Personal relationships 1.54 � 1.71 2.06 � 1.64 2.14 � 1.89 0.108

Leisure 3.46 � 3.12 4.73 � 3.47 5.37 � 2.70 0.005

Treatment-related effects 1.03 � 0.93 1.20 � 1.00 1.40 � 1.12 0.145

Total PDI 15.15 � 11.17 20.43 � 9.57 22.29 � 8.83 0.000

QoL, quality of life; PASI, psoriasis area and severity index; PDI, psoriasis disability index.aANOVA.



all areas of everyday life as assessed by PDI (daily activi-ties, employment, personal relationship, leisure, and treat-ment effects). Our results are in accordance with theprevious findings.28,29 Rakhesh et al.26 also found thathigh stress reactive patients with psoriasis had more over-all physical disability in almost all areas of everyday life(except for personal relationships). As it is known thatstress can worsen psoriasis,30–32 clinicians should beaware of these findings.When we compared disease severity (PASI scores) of

patients who were high stress reactors and of those whowere low stress reactors, the small difference found didnot reach statistical significance. Our finding is in agree-ment with the results of Gupta et al.,30 Fortune et al.,28

and Zachariae et al.,29 showing that two groups of reac-tors did not differ with respect to the usual dermatologi-cal criteria of psoriasis severity. However, the oppositeresults were achieved in several other studies.22,26,33

Our patients reported a higher level of stress due totheir body image, loss of self-esteem, and embarrassmentregarding their appearance, which is in accordance withthe results of other authors.13,26,28 The stress caused byshedding of the skin, feeling self-conscious among strang-ers, avoiding social contacts, and sunbathing in publicplaces was ranked higher than the stress caused byevents in which patients with psoriasis were discrimi-nated by other people. However, unpleasant reactions tochanges in the skin of patients with psoriasis are unfor-tunately a constant occurrence, but patients find a wayto avoid this situation or ignore it, to reduce anxiety andstress.34 This behavior may reduce the current sense ofstress, but it leads to further reduction in quality of life,due to various restrictions it brings along. The ability tocope with impairments and the availability of social sup-port may indeed affect the quality of life of patients withpsoriasis.Some limitations of the current study should be

mentioned. First, it was a cross-sectional study, thus mak-ing the findings limited. Second, the number of patientsstudied was relatively small. Finally, investigation of abroad concept such as quality of life may be affected byother possible confounders not considered here.In conclusion, our results suggest that psoriasis exerts

significant, negative impact on patients’ quality of lifeand emphasize the importance of psychological and socialfactors as predictors of quality of life. The associationbetween clinically assessed severity and quality of life inour study was generally weak. Patients who were classi-fied as more reactive to psoriasis-specific stress experi-enced significantly more disability in all areas of everydaylife. Our results support the importance of assessing thequality of life in psoriasis and effects of stress in patients’adjustment to their condition and may have important

implications for psychological stress management in theclinical management of psoriasis.

Acknowledgments

This work was supported by the Ministry of Education andScience, Republic of Serbia, Project No 175025. We aregrateful to Professor Andrew Finlay and Dr. MadhulikaGupta for their formal permission to translate and use thePDI and PLSI questionnaires, respectively.

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assessment of quality of life in patients with psoriasis: a study from serbia

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