Introduction

[|In this chapter it is
easy to disagreement by saying “yes, however…”. I think the various aspects
have been taken care of very well. But what we all miss is an overall score,
which comprises everything. Therefore, we need well-trained dermatologists for
professional decisions. I will explain what may happen if we assess disease
severity exclusively with nice scores as described in chapter 9. A patient with chronic
plaque psoriasis, PASI 7 visits the dermatologist. She has an alarming DLQI and
feels very depressed. Her psychiatrist considers adequate antidepressive
medication which is refused by the patient. As she could not stand photo
chemotherapy and none of the systemic treatments she now urges a biological
treatment. The resident was of the opinion that a biological treatment was
entirely justifiable. My view was entirely different. The patient did not need
a biological but an antidepressive drug.|auteur197]

[|This is an exceptionally well-done chapter, very broad in concept and discussion. The various outcome measures in psoriasis are well-discussed. The only addition that I would like to have seen would be a discussion on how dermatologists in clinical practice, ie non-academic centers, can assess these outcome measures in a rapid and informative way as measure such as SF36, PASI are seldom, if ever, done on a routine basis outside of clinical research or academic institutions. Is there a place for a new outcome measure that mirrors the ACR measure which uses quality of life, clinical evaluations, and even serological evaluations in one easily understood measurement? In this regard, Professor Jim Krueger will be hosting an International Psoriasis Council based Roundtable in February, 2006 with a new 4 part tool encompassing physical evaluation, quality of life, psoriatic arthritis and patient satisfaction undergoing clinical trial validations.. Two further outcome measures which have gained credibility in the United States are the PQOL (Psoriasis Quality of Life) developed by Professor John Koo from San Francisco, which has been validated in a large study with Drs. Lebwohl and Menter with over 400 patients, with concomitant clinical evaluation. From this PQOL, the Koo-Menter Psoriasis Index (KMPI) has been developed, a two-page index utilizing a series of patient-based 12 quality of life questions, and key questions relating to arthritic manifestations. This is then utilized to do a rapid body surface area evaluation after which key questions relating to access to phototherapy, etc., are discussed, with a final evaluation relating to patient applicability for systemic therapy, Yes or No. It is only by dermatologists and rheumatologists creating “easy to use” evaluations that psoriasis will finally be accepted as a systemic disease worthy of systemic treatment in those patients with moderate to severe disease, with or without associated psoriatic joint disease. This begs the question: What do we mean by mild, moderate, and severe psoriasis and how do quality of life issues relate to these artificial divisions? Thus, would somebody with palmar-plantar disease involving less than 5% BSA, with difficulties in ambulation and manual dexterity, not deserve systemic therapy as much as a patient with mild-moderate Crohn’s disease or mild-moderate rheumatoid arthritis? Again, a quality of life tool for palmar-plantar disease has been developed by our group and submitted for publication. Certainly, I would believe that such psoriatic patients have more disabling disease than the aforementioned conditions.|auteur215]

In life-threatening illnesses, it is the doctor who, with the help of scientifically validated clinical and biological markers, assesses the severity of the illness and, on the basis of this assessment, suggests the treatment with the best benefit/risk ratio.

In illnesses involving the quality of life—of which psoriasis is the prototype—only the patient can assess the illness’s repercussions on his or her quality of life, and hence its severity.

This severity, if any, justifies suggesting systemic treatments.

There is consensus or agreement between European psoriasis specialists to accept Professor Christopher Griffiths’ suggestion of assessing the severity of psoriasis by taking into consideration, in decreasing order of importance:

• the effect on the quality of life,
• the resistance of psoriasis to various treatments,
• the extent of the lesions.