Impact of psoriasis in the quality of life of children,adolescents and their families: a cross-sectional study

Background: Psoriasis is a chronic and inflammatory disease that impairs quality of life and causes psychological symptoms. Despite the high prevalence of psoriasis in pediatric patients, studies investigating the impact of psoriasis in the quality of life of children, adolescents and families are sparse.Objective: To investigate the impact of psoriasis in the quality of life of children and adolescents with psoriasis and their families and to determine depression and anxiety levels of the patients.Methods: A total of 58 patients with psoriasis aged 7-18 years (median age: 11) and a family member of each patient were included in the study. Children’s Dermatology Life Quality Index (CDLQI), Family Dermatology Life Quality Index (FDLQI), Children’s Depression Inventory (CDI) and State-Trait Anxiety Inventory for Children (STAIC) were used in the study.Results: The median PASI score of the patients included in the study was 1.8. The median CDLQI and FDLQI scores in the study groups were 5 and 10, respectively. The median CDI score, STAIC-state and STAIC-trait scores of the patients were 6, 28 and 32.5, respectively.Study limitations: Lack of a control group and patient assessment of disease severity. Relatively mild disease severity of the subjects.Conclusions: Psoriasis has a negative impact in the quality of life of children, adolescents and their families, even in the presence of mild disease. Considering that impairment in quality of life may be associated with psychosocial morbidity, a combined approach with medical therapy, family counseling and quality of life assessment may be beneficial in this patient group.     

PASI AND PQOL-12 SCORE IN PSORIASIS: IS THERE ANY CORRELATION?

Background:

Psoriasis, a common papulo-squamous disorder of the skin, is universal in occurrence and may interfere with the quality of life adversely. Whether extent of the disease has any bearing upon the patients’ psychology has not much been studied in this part of the world.

Aims:

The objective of this hospital-based cross-sectional study was to assess the disease severity objectively using Psoriasis area and severity index (PASI) score and the quality of life by Psoriasis quality-of-life questionnaire-12 (PQOL-12) and to draw correlation between them, if any.

Materials and Methods

PASI score denotes an objective method of scoring severity of psoriasis, reflecting not only the body surface area but also erythema, induration and scaling. The PQOL-12 represents a 12-item self-administered, disease-specific psychometric instrument created to specifically assess quality-of-life issues that are more important with psoriasis patients.PASI and PQOL-12 score were calculated in each patient for objectively assessing their disease severity and quality of life.

Results:

In total, 34 psoriasis patients (16 males, 18 females), of age ranging from 8 to 55 years, were studied. Maximum and minimum PASI scores were 0.8 and 32.8, respectively, whereas maximum and minimum PQOL-12 scores were 4 and 120, respectively. PASI and PQOL-12 values showed minimal positive correlation (r = +0.422).

Conclusion:

Disease severity of psoriasis had no direct reflection upon their quality of life. Limited psoriasis on visible area may also have greater impact on mental health.     

Reduction of Inter-Rater and Intra-Rater Variability in Psoriasis Area and Severity Index Assessment by Photographic Training

Background

Severity grading is important for the assessment of psoriasis treatment efficacy. This is most commonly achieved by using the psoriasis area and severity index (PASI), a subjective tool with inherent inter-rater and intra-rater variability. PASI-naive dermatologists require training to properly conduct a PASI assessment.

Objective

In the present study, we aimed to investigate whether photographic training improves inter-rater and intra-rater variabilities. We also determined which PASI component has the greatest impact on variability.

Methods

Twenty-one dermatologists received 1 hour of PASI training. They were tested before and after the training to evaluate intra-rater variability. The physicians were further tested after training by using a reference photograph.

Results

The mean of each PASI component was underevaluated compared with scoring by a PASI expert. The concordance rate with the expert''s grading was highest for thickness followed by erythema, scaling, and area. The scaling score showed the greatest improvement after training. After training, the distribution of deviation from the expert''s grading, which signifies inter-rater variability, improved only for the PASI area component. The deviation of scaling grading improved upon retesting by using a reference photograph.

Conclusion

PASI assessment training improved variabilities to some degree but not for every PASI component. The development of an objective psoriasis severity assessment tool will help overcome the subjective variabilities in PASI assessment, which can never be completely eliminated via training.     

Health-related quality of life among patients with moderate-to-severe plaque psoriasis in Taiwan

Background/Objectives

Plaque psoriasis is a debilitating condition that significantly affects patient well-being. Limited data are available regarding the effect of psoriasis and treatment on health-related quality of life (HRQoL) and work ability among Taiwanese patients.To document and compare HRQoL, treatment satisfaction, and work disability among Taiwanese patients with current and past moderate-to-severe plaque psoriasis.

The relationship between quality of life and the severity of psoriasis in Turkey

Background

Patients with psoriasis experience a low quality of life and high treatment burden

Objectives

To assess psoriatic patient quality of life using the Dermatology Life Quality Index (DLQI) in the Northeastern Anatolia region of Turkey. Additionally, we evaluated the correlation between the DLQI and the clinical severity of psoriasis and examined demographic data and their relationship with the DLQI and psoriasis severity

Materials and Methods

This study was a single-center, prospective, cross-sectional study at the University of Kafkas, Kars, Turkey. 127 adult patients were included in the study. TheTurkish version of the DLQI was used. To measure psoriasis severity, the Psoriasis Area Severity Index (PASI) and Body Surface Area (BSA) were simultaneously evaluated. The patient demographics were compared with quality of life and the severity of psoriasis

Results

DLQI scores ranged from “very large” to “extremely large” in 61% of the patients. The psoriasis severity (BSA and PASI) was “mild” in 63% of patients. The quality of life was significantly affected in cigarette smokers and in patients whose disease included nail involvement. The PASI and BSA scores of patients with scalp and nail involvement were significantly higher. A significant, positive correlation was found between disease duration and the severity of psoriasis. BSA correlated with PASI

Conclusion

The quality of life of psoriasis patients is strongly reduced. A significant relationship was found for DLQI with nail psoriasis and smoking. A linear, positive correlation was detected between the DLQI and BSA but not between the DLQI and PASI.

     

Impact of Psoriasis on Quality of Life: Relationship between Clinical Response to Therapy and Change in Health-related Quality of Life

Background

Psoriasis exerts significant, negative, impact on patients'' quality of life (QOL). Recently, the relationship between QOL and skin lesion improvement has been emphasized in the treatment of psoriasis patients.

Objective

The purpose of study was to compare the QOL in psoriasis and other skin diseases, and to evaluate the generic QOL, skin specific QOL, stress, depression and anxiety before and after treatment in patients.

Methods

A total of 138 patients with psoriasis were recruited in this study and 83 patients complete the questionnaire at week 16. Questionnaires were comprised of generic WHO QOL scale, dermatology specific questionnaires (Skindex-29), psoriasis life stress inventory (PLSI), Beck depression inventory (BDI), and Beck anxiety inventory (BAI). Clinical response was assessed by the PASI.

Results

After treatment, health-related QOL was improved and PASI improvement showed smaller correlation with Skindex-29, compared with the correlations between self-reported severity score (SRSS) improvement and Skindex-29. Regression analysis revealed that duration, SRSS, stress, and depression were factors affecting baseline HRQOL in patients, and age, duration, and SRSS were predictors associated with HTQOL score changes.

Conclusion

Treatment improved HRQOL, BAI, BDI, and PLSI scores. Psoriasis may become more burdensome in groups of patients who suffer long disease duration, high SRSS, depression, and stressful environments.     

Determinants of quality of life in psoriasis patients: a cluster analysis of 50 patients

Background:

Although psoriasis generally does not affect survival, it certainly has a number of major negative effects on patients, demonstrable by a significant detriment to quality of life.

Aims:

We have done a study with the objective of assessing the clinical variables adversely affecting quality of life in patients diagnosed with psoriasis.

Materials and Methods:

This study is a cluster analysis of 50 consecutive consenting patients with psoriasis, of both sexes, aged over 18 years, attending the dermatology outpatient department of a tertiary care center. We measured the clinical severity using psoriasis area severity index and health-related quality of life using psoriasis disability index (PDI). Statistical analysis was performed using unpaired independent student''s t-test, analysis of variance (and Scheffe''s post hoc test as appropriate) and Pearson''s correlation coefficients.

Results:

There was a significant correlation between the physician-rated severity of psoriasis and the extent of impact of psoriasis on physical disability as measured by the PDI. We have identified that a younger age at onset of disease and self-reported stress exacerbators suffer greater disability in most aspects of quality of life.

Conclusions:

On the basis of this study, we would recommend that psoriasis patients especially with severe disease require a more holistic treatment approach that encompasses both medical and psychological measures.     

Quality of Life in Family Members of Vitiligo Patients: A Questionnaire Study in Saudi Arabia

Background

Many dermatologic disorders are known to adversely affect quality of life (QoL) in close relatives or partners of patients; however, it is unknown whether vitiligo impacts the QoL of family members.

Objective

The aim of this study was to identify the level and domains in which the QoL of partners/relatives of patients with vitiligo are affected by the disease.

Methods

A total of 141 patients with vitiligo, along with their family members, were recruited to complete validated QoL questionnaires, including the Dermatology Life Quality Index (DLQI) and the Family Dermatology Life Quality Index (FDLQI).

Results

Family member QoL was affected in 129 (91.5 %) of subjects. Mean FDLQI score was 10.3 ± 6.4 standard deviation. Higher FDLQI score (greater impairment in QoL) was significantly associated with male patients, a shorter duration of disease, and higher educational levels in family members. The most affected FDLQI items in order of decreasing incidence were emotional impact, burden of care, impact on the physical well-being of the family member, problems due to the reaction of others in response to the patient’s skin appearance and effect on social life. Overall FDLQI score and the number of items affected correlated with overall patient DLQI score (p < 0.001, r = 0.56 and p < 0.001, r = 0.53, respectively).

Conclusions

Vitiligo has a major impact on the QoL of family members of patients and often significantly impairs many aspects of their lives. Educational and supportive programs are recommended for family members of vitiligo patients who are at an increased risk for QoL impairments.     

Severity of Psoriasis Among Adult Males is Associated with Smoking,Not with Alcohol Use

Context:

Lifestyle factors such as tobacco smoking and alcohol use can affect the presentation and course of psoriasis. There is a paucity of data on this subject from India.

Aims:

To find out whether increased severity of psoriasis in adult Indian males is associated with tobacco smoking and alcohol use.

Settings and Design:

Cross-sectional study in the Department of Dermatology of a Tertiary Care Teaching Hospital.

Subjects and Methods:

Male patients above 18 years of age attending a psoriasis clinic between March 2007 and May 2009 were studied. Severity of psoriasis (measured using Psoriasis Area and Severity Index – PASI) among smokers and non-smokers was compared. We also studied the correlation between severity of psoriasis and nicotine dependence (measured using Fagerström Test for Nicotine Dependence) and alcohol use disorders (measured using Alcohol Use Disorders Identification Test–AUDIT).

Statistical Analysis:

Z-test, Odd''s ratio, Chi-square test, Spearman''s correlation coefficient.

Results:

Of a total of 338 patients, 148 were smokers and 173 used to consume alcohol. Mean PASI score of smokers was more than that of non-smokers (Z-test, z = −2.617, P = 0.009). Those with severe psoriasis were more likely to be smokers (χ² = 5.47, P = 0.02, OR = 1.8, Confidence Interval 1.09-2.962). There was a significant correlation between PASI scores and Fagerström score (Spearman''s correlation coefficient = 0.164, P < 0.01). Mean PASI scores of persons who used to consume alcohol and those who did not were comparable.(Z-test, z = −0.458, P = 0.647). There was no association between severity of psoriasis and alcohol consumption.(χ² = 0.255, P = 0.613, Odds Ratio = 1.14, CI 0.696-1.866). There was no correlation between PASI scores and AUDIT scores (Spearman''s correlation coefficient = 0.024, P > 0.05).

Conclusions:

Increased severity of psoriasis among adult males is associated with tobacco smoking, but not with alcohol use.     

Effects of alefacept on health-related quality of life in patients with psoriasis: results from a randomized,placebo-controlled phase II trial

Introduction

Chronic plaque psoriasis has a profound impact on patient quality of life (QOL), including adverse psychosocial effects, impaired daily activities, anxiety, and depression.

Objective

To assess health-related QOL in a randomized phase II trial of alefacept (human LFA-3/IgG₁ fusion protein), a selective immunomodulator for psoriasis.

Study design

Multicenter, randomized, placebo-controlled, double-blind trial.

Methods

229 patients with moderate to severe psoriasis were randomized to alefacept (0.025, 0.075, or 0.150 mg/kg) or placebo by 30-second intravenous bolus once weekly for 12 weeks and followed for 12 additional weeks. Patients completed a general (SF-36®¹ Health Survey) and dermatology-specific (Dermatology Life Quality Index [DLQI] and Dermatology Quality Of Life Scales [DQOLS]) QOL surveys at each study visit.

Results

Patients treated with alefacept had significantly greater improvements on dermatology-specific QOL scales compared with patients receiving placebo (p < 0.05). Patients who achieved a ≥50% or a ≥75% reduction in Psoriasis Area and Severity Index (PASI) reported similar improvement in QOL, which was significantly greater than that of other patients.

Conclusions

The clinical effect of alefacept on psoriasis is associated with an improvement in patients’ QOL. Among patients with moderate to severe psoriasis, an improvement in PASI of 50% or more is associated with better QOL scores.     

Psoriasis: is it the tip of the iceberg for the quality of life of patients and their families?

Objective To evaluate the impact of psoriasis on patients’ and their relatives’ quality of life (QoL). Methods Eighty patients with their accompanying family members were included in the study. For measuring health related QoL (HRQoL) of patients with psoriasis, two questionnaires were used: Short Form 36 Health Survey (SF‐36) and EuroQol (EQ‐5D). Disease‐specific HRQoL was assessed by the Dermatology Life Quality Index. For measuring the quality of life of patients’ relatives, a specific questionnaire for dermatological diseases was used (Family Dermatology Life Quality Index, FDLQI). Results Of our patients, 88.3% reported that their disease affects in many and different ways their QoL whereas only 11.2% reported that psoriasis does not influence at all their life. Regarding FDLQI, 90% of the participating family members, responded that their relative’s psoriasis affected their own QoL. Conclusions Psoriasis is a chronic disease that affects in a cumulative way the quality of life of both patients and their close relatives.     

A cross‐sectional study using the Children’s Dermatology Life Quality Index (CDLQI) in childhood psoriasis: negative effect on quality of life and moderate correlation of CDLQI with severity scores

Background Juvenile psoriasis is a chronic and incurable skin disease that affects approximately 0·7% of children. Objectives To achieve more insight into the quality of life (QoL) in childhood psoriasis and to investigate whether disease severity scores correlate with QoL scores. Methods All consecutive patients with juvenile plaque psoriasis (≤ 18 years old) who visited our outpatient department were included. At baseline, the Children’s Dermatology Life Quality Index (CDLQI) questionnaire was completed and disease severity was assessed by the Psoriasis Area and Severity Index (PASI) and the Physician Global Assessment (PGA). Results Thirty‐nine patients were included in the study. A median CDLQI of 6 [interquartile range (IQR) 5–9] was reported. Median PASI was 6·3 (IQR 3·3–8·2) and median PGA was 2 (IQR 1–3). The correlation coefficient between PASI and CDLQI was 0·47 (P = 0·003), whereas the correlation coefficient between PGA and CDLQI was 0·51 (P = 0·001). Conclusions The negative effect on QoL in juvenile psoriasis was confirmed in the largest cohort presented up to now. The correlation between disease severity scores and disease‐related QoL in children with psoriasis is only moderate. Therefore, both clinical outcome parameters (PASI, PGA) and measures of QoL (CDLQI) should be included in adequate, patient‐oriented clinical decision making.     

Quality of life and psychosocial aspects in Greek patients with psoriasis: a cross-sectional study

BACKGROUND

Psoriasis is a common, long-term skin disease associated with high levels of psychological distress and a considerable adverse impact on life. The effects of psoriasis, beyond skin affliction, are seldom recognized and often undertreated.

OBJECTIVE

The aim of the study is to evaluate the quality of life, anxiety and depression, self-esteem and loneliness in patients with psoriasis.

METHODS

Eighty-four patients with psoriasis were enrolled in the study. The quality of life, depression and anxiety, loneliness and self-esteem of the patient were assessed using the Dermatology Life Quality Index, Hospital Anxiety and Depression Scale, the UCLA loneliness Scale (UCLA-Version 3) and Rosenberg''s Self-esteem Scale, respectively.

RESULTS

The Dermatology Quality of Life Index score among psoriasis patients was 12.61 ± 4.88. They had statistically significantly higher scores according to the Hospital Anxiety and Depression Scale -anxiety subscale (p=0.032)-compared with healthy volunteers. Moreover, a statistically significant difference was found between the two groups concerning the UCLA-scale (p=0.033) and RSES-scale (p<0.0001). Female patients presented with lower self-esteem than male patients.

CONCLUSION

Psoriasis is a distressing, recurrent disorder that significantly impairs quality of life. Therefore, the recognition and future management of psoriasis may require the involvement of multi-disciplinary teams to manage the physical, psychological and social aspects of the condition, as is the case for systemic, long-term conditions.     

Effectiveness of Conventional Drug Therapy of Plaque Psoriasis in the Context of Consensus Guidelines: A Prospective Observational Study in 150 Patients

Background

Evidence for superior outcome by adhering to therapy guidelines is imperative to their acceptance and adaptation for the optimal management of disease variants.

Objective

Comparative study of prospective outcomes in simultaneous consideration of independent variables in groups of 150 patients of plaque psoriasis either treated adhering to or in digression of standard guidelines.

Methods

The psoriasis area severity index (PASI) and the dermatology life quality index (DLQI), prior to and after three months of uninterrupted therapy were examined in treatment groups among 150 patients. Recovery rates of 75% or more in PASI were compared. Independent variables were also examined for their bearing on the outcome.

Results

The vast majority was early onset disease phenotype. All three treatment regimens when administered in adherence to the guidelines yielded significantly superior rates of defined recovery both in PASI and DLQI. Compromise of the therapeutic outcome appeared in high stress profiles, obesity, female sex and alcohol, tobacco or smoking habit.

Conclusion

Conventional drug therapy of plaque psoriasis yields superior outcome by adhering to the consensus guidelines. Psychiatric address to stress must be integral and special considerations for phenotypic/syndromic variants is emphasized for effective therapy of psoriasis.     

Assessing depression and anxiety in the caregivers of pediatric patients with chronic skin disorders

BACKGROUND

The literature has shown that the presence of emotional disturbances in caregivers of children with skin diseases affects the course and treatment of the disease. Anxiety and depression are among the most frequently reported psychiatric diagnoses related to this fact.

OBJECTIVE

To evaluate the presence of anxiety and depression in caregivers of pediatric patients with chronic skin disorders, exemplified by atopic dermatitis, psoriasis and vitiligo, and correlate them to the quality of life of the patients.

METHODS

The sample consisted of 118 patients with atopic dermatitis, vitiligo and psoriasis, monitored by their main caregiver. The levels of anxiety and depression in the caregivers were assessed using the Hamilton Anxiety Scale and the Beck Depression Inventory, respectively. The Children''s Dermatology Life Quality Index was applied.

RESULTS

Anxiety was observed in 36% of the caregivers of the patients with atopic dermatitis, in 36% of those of children affected by psoriasis, and in 42% of those responsible for pediatric patients with vitiligo. Depression occurred in 36% of the caregivers of patients with atopic dermatitis, in 36% of those of children affected by psoriasis and in 26% of those responsible for pediatric patients with vitiligo. There was a significant correlation between poor quality of life scores in patients with vitiligo and the presence of depression and anxiety in their caregivers.

CONCLUSION

Emotional disorders tend to be present among close family members of children with the chronic skin diseases studied and their prevention can help in controlling and treating these diseases.     

Anti-TNFα therapy in the management of psoriasis: experience of a state referral center

BACKGROUND

Psoriasis is a chronic immune-mediated disease, characterized by increased levels of TNFα. Anti-TNFα agents have revolutionized the treatment of severe psoriasis by targeting an important molecule involved in its pathogenesis.

OBJECTIVES

We report the experience of a state referral center that uses anti-TNFα agents for psoriasis.

METHODS

We conducted a retrospective case series. Seventy-four out of 120 patients met the inclusion criteria. Clinical and laboratory data was analyzed using the chi-squared, Wicoxon and McNemar''s tests. Associations were considered statistically significant when p-value<0.05.

RESULTS

Forty-one subjects (55.40%) were male, with a mean age of 47.69±14.99 years. Median disease duration and pre-treatment PASI were 14.0 months (IQR 9.0-20.0), and 13.55 points (IQR 8.5-20.32). Sixty patients (81.10%) had arthropathic psoriasis. Forty-six subjects (62.20%) had comorbidities; the most frequent was dyslipidemia (25.70%). In 55.40% of patients, insufficient response to conventional therapies was the principal indication for using anti-TNFα drugs. Clinical improvement occurred in 93.20% of cases, and the post-treatment PASI median was 0.0 points (IQR 0.0-0.0). Adverse effects occurred in 6.80% of patients. Infections and elevation of transaminases occurred in 28.40% and 8.10% of cases, respectively.

CONCLUSION

Post-treatment reduction in PASI was satisfactory and the occurrence of adverse effects was minor, mostly mild infusion effects and local reactions at drug administration sites.     

Associations between maternal socioeconomic position and psoriasis: a cohort study among the offspring of the Danish National Birth Cohort

Psoriasis is a common skin disease that is often characterized by well-defined red or scaly patches on the skin. The disease affects approximately 0.4 percent of children in Denmark, with similar rates in other western countries. Psoriasis occurring in childhood may be referred to as paediatric-onset psoriasis. In this Danish study, the authors aimed to find out whether children with a lower socioeconomic position (from families with lower education, income and employment) were more likely to suffer from paediatric-onset psoriasis compared to those with a higher socioeconomic position. The authors used data from a study in which mothers and their children participated from pregnancy and the children's birth until the children were 11 years old. At the 11-year follow-up of children, mothers were asked whether their child had psoriasis. Information on socioeconomic position was gathered by using data from official databases on the mothers’ income, education and work. The authors investigated whether these factors affected the chances of their child developing paediatric-onset psoriasis and found that they were strongly related. Children whose mothers had a lower education or income were more likely to have paediatric-onset psoriasis than children whose mothers had a higher education or income. Social and economic circumstances at birth and in childhood appear to play a role in the risk of getting paediatric-onset psoriasis.     

The influence of treatments in daily clinical practice on the Children's Dermatology Life Quality Index in juvenile psoriasis: a longitudinal study from the Child-CAPTURE patient registry

Background Juvenile psoriasis has a negative effect on the quality of life (QoL). The influence of treatments on QoL of these children has never been investigated before in a prospective observational study. Objectives To assess the Children’s Dermatology Life Quality Index (CDLQI) in a cohort of patients with juvenile psoriasis and to evaluate the influence of treatments in daily clinical practice on CDLQI. Methods We conducted a prospective observational study of children with psoriasis from a registry containing daily clinical practice data. Before and after treatment, QoL was assessed by the CDLQI and disease severity was documented by the Psoriasis Area and Severity Index (PASI). Three clusters of treatments were analysed: topical, dithranol and systemic therapy. Results In total, 125 patients were enrolled in the registry. Cross‐sectionally, a mean ± SD CDLQI score of 7·5 ± 5·0 and a mean ± SD PASI of 7·0 ± 5·8 were recorded. Itching and problems with treatment had the highest impact on the children’s QoL. Longitudinally, 85 patients were analysed with a total of 137 treatment episodes. All treatments contributed to a significant decline in total CDLQI score, with the largest decrease seen in dithranol and systemic treatments. A significant correlation was found between ΔCDLQI and ΔPASI for all treatment modalities. The highest positive impact of treatments was found in a decline of itch and sleep disturbance. Conclusions In this first prospective observational study on CDLQI in juvenile psoriasis, a positive influence of treatments in daily clinical practice on QoL was demonstrated.     

Safe Psoriasis Control: A New Outcome Measure for the Composite Assessment of the Efficacy and Safety of Psoriasis Treatment

Background

PASI is an inadequate outcome measure for the assessment of psoriasis treatments. No currently used endpoints provide a benefit: risk assessment of treatment taking into consideration all available efficacy and safety data.

Objective

To propose a new outcome measure called “safe psoriasis control” (SPC), which assesses multiple dimensions of the disease in a clinically meaningful way through the combined use of appropriate efficacy, quality of life, and safety data.

Methods

Data from 3,500 subjects were used for the purpose of derivation and validation of the SPC endpoint. Advanced statistical methodology was used to evaluate and validate important components in the assessment of therapeutic benefit.

Results

SPC was shown to be a simple but meaningful combined endpoint showing the proportion of patients who had treatment benefit without major side effects.

Conclusion

The SPC endpoint may be a step-forward in providing a composite tool for the evaluation of treatments for psoriasis.