Empowering Heliotherapy in Psoriasis and Atopic Dermatitis: An Observational Study of 186 Subjects

Ac aDV Ac aDV 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 Ad ances in de ma ology and ene eology Ac a De ma o-Vene eologica Sho communica ion256 www.medicaljou nals.se/ac a 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. 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