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Ad ances in de ma ology and ene eology Ac a De ma o-Vene eologica
SHORT COMMUNICATION
Ac a De m Vene eol 2017; 97: 255–257
This is an open access a icle unde he CC BY-NC license. www.medicaljou nals.se/ac a
Jou nal Compila ion © 2017 Ac a De ma o-Vene eologica.
doi: 10.2340/00015555-2506
255
Pso iasis and a opic de ma i is (AD) ha e a nega i e
impac on pa ien s’ heal h- ela ed quali y o li e (HRQoL)
(1, 2). The e is a long adi ion o helio he apy (HT) in he
Cana y Islands o he ea men o Finnish pa ien s wi h
pso iasis and AD (3, 4), and he cou ses ha e ecen ly
been upda ed o include mo e empowe ing elemen s.
The p esen model o empowe ing helio he apy (EHT)
consis s o mee ing pee s, adop ing a heal hy li es yle,
pe o ming exe cise, and gaining inc eased au onomy.
The bene i s o he new EHT ha e been shown o
pa ien s wi h pso iasis and hose wi h AD (5, 6). This
s udy is a sequel o ou pilo s udy (5) and p o ides mo e
e idence o he e ec s o EHT.
METHODS ( o comple e de ails see Appendix S1
1
)
Two-week EHT cou ses we e a anged in Pue o Rico (27°N,
15°W), Cana y Islands, Spain, be ween Oc obe 2012 and Ap il
2013. The cou se included an educa ion day be o e EHT and a
eunion weekend 3 mon hs la e . O pa ien s a ending he cou ses,
133/168 o hose wi h pso iasis and 60/72 o hose wi h AD pa i-
cipa ed in he s udy, bu 7 we e excluded om he analyses. Use
o sys emic and opical medica ion, as p esc ibed and p e iously
used, was allowed du ing he s udy pe iod. Sunba hing ime a ied
acco ding o he Fi zpa ick’s skin pho o ype (7), season, disease
g oup and se e i y, being ini ially 20–90 min o pso iasis and
15–30 min o AD. Du ing he i s EHT week, daily exposu e
ime was inc eased o 90 min and up o 300 min o pso iasis and
120 min o AD in cases o skin pho o ype IV.
HRQoL was assessed wi h he De ma ology Li e Quali y Index
(DLQI) (8) and RAND-36 (4-week e sion), o which physical
componen summa y (PCS) and men al componen summa y
(MCS) sco es we e calcula ed (9). Disease se e i y was assessed
wi h he Sel -Adminis e ed Pso iasis A ea and Se e i y Index
(SAPASI) (10) and Pa ien -O ien ed Sco ing o A opic De ma i is
(PO-SCORAD) (11). Disease se e i y and p u i us we e assessed
using a isual analogue scale (VAS) (12). Sel -assessmen s we e
pe o med du ing he educa ion day (T1), a e e u ning home
om EHT (T2) and 3 mon hs a e T2 (T3). Fou poin s was
conside ed he minimal clinically impo an change in DLQI (13).
Da a we e analysed using gene alizing es ima ing equa ion models
(S a a 14.0 S a is ical Package o S a aCo p LP, College S a ion,
TX, USA). The p o ocol was app o ed by he e hics commi ee o
Tampe e Uni e si y Hospi al (numbe : o R12219). All pa icipan s
ga e hei in o med consen .
RESULTS
The mean age o he pa ien s wi h pso iasis was 51 yea s
( ange 20–75 yea s), 70 (55%) emales, 67 (53%) wi h
pso ia ic a h i is. Fi zpa ick’s skin pho o ype (II/III/
IV) dis ibu ion was 21/97/9. Thi y-eigh pa ien s (30%)
we e aking a sys emic d ug o pso iasis. Mean baseline
SAPASI sco e was 7.4 (95% con idence in e al (95%
CI) 6.4–8.5).
The mean age o he pa ien s wi h AD was 37 yea s
( ange 19–74 yea s), 50 (85%) emale. Fi zpa ick’s skin
pho o ype (II/III/IV) dis ibu ion 11/44/4. Mean baseline
PO-SCORAD sco e was 36.8 (95% CI 32.7–40.9).
The DLQI sco e and he RAND-36 summa y sco es
(PCS and MCS) dec eased signi ican ly o bo h pa ien
g oups om he baseline (T1) o he end o he EHT (T2)
(p < 0.001, Tables SI and SII
1
). DLQI sco es emained
signi ican ly dec eased ela i e o T1 in bo h pa ien
g oups (p < 0.001) 3 mon hs a e he EHT (T3). The
minimal clinically impo an di e ence (MCID) o 4
poin s (13) was achie ed by 34/92 pa ien s wi h pso iasis
(37%) and 26/45 pa ien s wi h AD (58%). The RAND-36
summa y sco es (PCS and MCS) emained signi ican ly
imp o ed ela i e o baseline (T1) o 3 mon hs a e he
EHT (T3) in bo h pa ien g oups (Tables SI and SII
1
). The
change in global VAS had a mode a ely posi i e co ela-
ion wi h he DLQI sco es (
2
= 0.40), bu i s co ela ions
wi h he PCS and MCS sco es we e weak (
2
= 0.08 and
2
= 0.03) (Fig. S1
1
).
The SAPASI sco e was dec eased by 5.0 om 7.4 ± 5.8
be ween T1 and T2 (p < 0.001) and he PO-SCORAD
sco e by 24.0 om 36.8
± 15.5 (p < 0.001). A 75% clea-
ance was seen in 59 pa ien s wi h pso iasis (46%) and
27 pa ien s wi h AD (46%). VAS showed a signi ican
decline in disease se e i y and p u i us in bo h g oups
(p < 0.001) (Table SI
1
). Baseline disease se e i y and i s
imp o emen we e independen o he ime o yea and
sunba hing ime in bo h disease g oups. Th ee mon hs
a e he EHT (T3) he SAPASI and PO-SCORAD sco es
we e s ill signi ican ly lowe han a T1 (p < 0.001), and
he VAS sco es we e also signi ican ly lowe in bo h
g oups (Table SI
1
).
The pa ien s we e di ided in e ms o se e i y in o
mild and mode a e- o-se e e subg oups, he cu -o
poin s being a SAPASI sco e o 10 and a PO-SCORAD
sco e o 25.
Pa ien s wi h mild pso iasis (n = 86) had a mean age
o 51 yea s ( ange 23–72), 62% we e emales and hei
baseline DLQI was 6.7
± 4.8, whe eas pa ien s wi h
mode a e- o-se e e pso iasis (n = 33) had a mean age
o 48 yea s ( ange 20–71 yea s), 52% we e emales and
Empowe ing Helio he apy in Pso iasis and A opic De ma i is: An Obse a ional S udy o 186 Subjec s
Toni KARPPINEN
1,2
, Juha-Pekka LAINE
1
, Hannu KAUTIAINEN
3
, Ra ael PASTERNACK
2
, Timo REUNALA
1
and E na SNELLMAN
1,2
1
Medical School, Uni e si y o Tampe e,
2
Depa men o De ma ology, Tampe e Uni e si y Hospi al, PO Box 2000, FIN-33521, Tampe e,
and
3
Uni o P ima y Heal h Ca e, Helsinki Uni e si y Cen al Hospi al, and Depa men o Gene al P ac ice, Uni e si y o Helsinki, and Uni
o P ima y Heal h Ca e, Kuopio Uni e si y Hospi al, Helsinki and Kuopio, Finland. E-mail: [email p o ec ed]
Accep ed May 31, 2016; Epub ahead o p in Jul 7, 2016
1h ps://www.medicaljou nals.se/ac a/con en /abs ac /10.2340/00015555-2506
Ac aDV Ac aDV
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Sho communica ion256
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hei baseline DLQI was 11.0 ± 6.0. The o me had a
mean DLQI imp o emen o 1.7
± 5.4 and he la e o
5.3 ± 6.0, he la e also being clinically signi ican (13).
The g oups di e ed signi ican ly only in hei baseline
DLQI (p < 0.001).
The pa ien s wi h mild AD (n = 16) had a mean age
o 39 yea s ( ange 20–74 yea s), 88% we e emale, and
hei baseline DLQI was 5.6
± 3.1, whe eas hose wi h
mode a e- o-se e e AD (n = 43) had a mean age o 37
yea s ( ange 19–65 yea s), 84% we e emale, and hei
baseline DLQI was 12.2
± 5.2. The o me had a mean
DLQI imp o emen o 1.1 ± 2.9 and he la e 6.3 ± 4.2, he
la e being clinically signi ican (13). The g oups di e-
ed signi ican ly only in hei baseline DLQI (p < 0.001).
DISCUSSION
The EHT imp o ed he HRQoL and alle ia ed disease
se e i y in he pa ien s wi h pso iasis and hose wi h AD
o a leas 3 mon hs. A la ge p opo ion o he pa ien s
wi h AD (58%) han o he pa ien s wi h pso iasis (37%)
achie ed a clinically signi ican DLQI imp o emen ,
possibly because o hei ini ially mo e se e e disease.
The RAND-36 PCS sco e imp o ed mo e in he pa ien s
wi h pso iasis, and he MCS sco e in he pa ien s wi h
AD. The schedule o he pa ien s wi h pso iasis included
mo e physical exe cise, wi h he aim o inspi ing hem
o educe hei isk o como bidi ies and alle ia ing
symp oms ela ed o pso ia ic a h i is. The di e ence
in cou se con en mus be kep in mind when compa ing
he esul s be ween he g oups.
Al hough he ini ial SAPASI was low (7.4), indica ing
mild disease, he p opo ion o pa ien s wi h pso iasis
who achie ed 75% clea ance was only mode a e (46%),
which could ha e been due o he sho du a ion o he
EHT o o he insensi i i y o SAPASI wi h ega d o a
mild disease s a e. Pso iasis in gene al equi es mo e
han 2 weeks o any pho o he apy o achie e alle ia ion.
As epo ed by Wahl e al. (6) in a simila se ing, he
SAPASI was s ill signi ican ly educed a e 3 mon hs.
The ini ial PO-SCORAD sco e epo ed he e (36.8) and
i s imp o emen a e 3 mon hs a e in ag eemen wi h
he esul s p esen ed ea lie by Au io e al. (4).
Pa ien educa ion as an adjunc o ea men is a no-
el elemen in he long- e m ea men o ch onic skin
diseases. Teaching in sel -ca e, pee - o-pee suppo ,
wo kshops, elaxa ion p ac ice and mul idisciplina y
discussion g oups ha e been shown o imp o e he
HRQoL o such pa ien s (14). The new EHT combines
hese me hods wi h adi ional helio he apy. Du ing an
EHT cou se he pa ien s a e away om hei homes and
jobs and in a s ess- ee en i onmen oge he wi h pee s.
Since a leas 5 o he ques ions in DLQI a e ela ed o
home en i onmen , wo k and pe sonal ela ionships,
DLQI sco es immedia ely a e e u ning home mus be
in e p e ed wi h cau ion. The challenge o EHT is how
o main ain he e ec s in he long e m a e e u ning
o no mal li e (6).
The e a e ce ain limi a ions in he s udy design, such
as he lack o a con ol g oup. To demons a e he supe-
io i y o EHT compa ed wi h HT, he pa ien s should
be andomized o ecei e ei he adi ional HT o EHT.
This is di icul , since he new EHT model has become
a ou ine p ac ice. The e is also no long- e m DLQI da a
om pas adi ional HT cou ses a anged in he Cana y
Islands o compa e hese new esul s. Empowe men
can be assessed wi h no el ools, such as he Heal h
Educa ion Impac Ques ionnai e (heiQ) measu ing illness
pe cep ion, sel -managemen and coping (6), bu un o -
una ely hese we e no commonly used in de ma ology
when we we e planning he p esen s udy. Ou p ima y
ocus was o demons a e how empowe men me hods
and alle ia ion o disease se e i y imp o e HRQoL,
which we conside he mos impo an end-poin . The
season o EHT o sun exposu e ime did no seem o
a ec he ou comes du ing EHT, bu d ug adjus men s
we e allowed du ing he 3-mon h ollow-up, which migh
ha e had an e ec on ou comes.
ACKNOWLEDGEMENTS
The au ho s hank he Finnish Pso iasis Associa ion and he Fin-
nish Cen al O ganisa ion o Skin Pa ien s o hei collabo a ion.
The wo k was suppo ed by Compe i i e S a e Resea ch Finan-
cing om he Expe Responsibili y A ea o Tampe e Uni e si y
Hospi al.
The au ho s decla e no con lic s o in e es .
REFERENCES
1. Augus in A, Rad ke MA. Quali y o li e in pso iasis pa ien s.
Exp Re Pha macoecon Ou comes Res 2014; 14: 559–568.
2. Maksimo ic N, Janco ic S, Ma inko ic J, Sekulo ic L, Zi ko-
ic Z, Spi ic V. Heal h- ela ed quali y o li e in pa ien s wi h
a opic de ma i is. J De ma ol 2012; 39: 42–47.
3. Snellman E, Lauha an a J, Reunanen A, Jansen CT, Jy kinen-
Pakkas i a T, Kallio M, e al. E ec o helio he apy on skin
and join symp oms in pso iasis: a 6-mon h ollow-up s udy.
B J De ma ol 1993; 128: 172–177.
4. Au io P, Komulainen P, La ni HM. Helio he apy in a opic
de ma i is: a p ospec i e s udy on clima o he apy using he
SCORAD index. Ac a De m Vene eol 2002; 82: 436–440.
5. Ka ppinen TT, Ylian ila L, Kau iainen H, Reunala T, Snellman
E. Empowe ing helio he apy imp o es clinical ou come and
quali y o li e o pso iasis and a opic de ma i is pa ien s. Ac a
De m Vene eol 2015; 95: 579–582.
6. Wahl AK, Langeland E, La sen M, Robinson H, Osbo ne R,
K ogs ad A. Posi i e changes in sel -managemen and disease
se e i y ollowing clima e he apy in people wi h pso iasis.
Ac a De m Vene eol 2015; 95: 317–321.
7. Fi zpa ick TB. The alidi y and p ac icali y o sun- eac i e
skin ypes I h ough IV. A ch De ma ol 1988; 124: 869–871.
8. Finlay AY, Khan GK. De ma ology Li e Quali y Index – a simple
p ac ical measu e o ou ine clinical use. Clin Exp De ma ol
1994; 19: 210–216.
9. Hays R, Mo ales L. The RAND-36 measu e o heal h- ela ed
quali y o li e. Ann Med 2001; 33: 350–357.
10. Feldman SR, Fleische AB, Reboussin DM, Rapp SR, Exum
ML, Cla k AR, e al. The Sel -Adminis e ed Pso iasis A ea
and Se e i y Index is alid and eliable. J In es De ma ol
Ac aDV Ac aDV
Ad ances in de ma ology and ene eology Ac a De ma o-Vene eologica
257Sho communica ion
Ac a De m Vene eol 2017
1996; 106: 183–186.
11. S alde JF, Ba ba o S, Wollenbe g A, Holm EA, De Rae e L,
Seidena i S, e al. Pa ien O ien ed SCORAD (PO SCORAD):
a new sel -assessmen scale in a opic de ma i is alida ed
in Eu ope. Alle gy 2011; 66: 1114–1121.
12. Shikia R, B esnahan BW, S one SP, Thompson C, Koo J, Re-
icki DA. Validi y and eliabili y o pa ien - epo ed ou comes
used in pso iasis: esul s om wo andomized clinical ials.
Heal h Qual Li e Ou comes 2003; 1: 53.
13. Bas a MKA, Salek MS, Camille i L, S u key R, Finlay AY.
De e mining he minimal clinically impo an di e ence and
esponsi eness o he De ma ology Li e Quali y Index (DLQI):
u he da a. De ma ology 2015; 230: 27–33.
14. de Bes J, Legie se CM, P insen CA, de Ko e J. Pa ien edu-
ca ion in ch onic skin diseases: a sys ema ic e iew. Ac a
De m Vene eol 2011; 91: 12–17.