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For 2% to 4% of people worldwide, symptoms associated with psoriasis can have a significant negative impact on quality of life. Studies have shown that 40% to 95% of patients with psoriasis view itch as the most important factor in disease severity, and that skin pain is a common symptom in up to 90% of patients.

Perhaps not surprisingly, there is that the use of analgesics, including opioids, is higher in patients with psoriasis than in the general population. Until recently, it has been unclear whether this is in response to skin pain or to joint pain associated with (PsA), which eventually develops in 20% of patients.

Findings from a recent cross-sectional study of symptoms, disease burden, and the use of analgesics in patients with psoriasis supports earlier findings and provides some answers for the questions that remain. Investigators led by Nikolai Loft, MD, of Copenhagen University Hospital -- Herlev and Gentofte Hospital, in Copenhagen, Denmark, analyzed data from the prospective, survey-based of 4,016 patients with moderate to severe psoriasis, including 847 with concomitant PsA and 3,490 reference controls.

Loft and colleagues found that the increased severity of skin symptoms in patients with psoriasis was associated with the use of NSAIDs, opioids, acetaminophen (Paracetamol), and gabapentin (Neurontin), and had a higher impact on quality of life compared with the reference controls. However, in multivariate logistic regression analysis controlling for symptoms, only joint pain was associated with the use of analgesics (odds ratio 3.72, p<0.0001).

"Patients with psoriasis have a high occurrence of joint symptoms and in line with a y, we found use of opioids to be higher among patients with psoriasis," the study authors wrote. "[However], when adjusting for joint pain, the apparent association between skin pain or itch and use of analgesics was no longer observed," they wrote in the

Notably, moderate-to-severe joint pain was reported by more than two-thirds of the 847 patients with concomitant PsA. It was also reported by about 50% of patients without a diagnosis of PsA, suggesting undiagnosed PsA in some patients. The researchers pointed out that patients with psoriasis could have ultrasonographic entheseal abnormalities that are clinically asymptomatic. The increased use of of opioid analgesia in this subgroup could be the result of under-treatment, they said.

Symptoms are important contributing factors to the burden of psoriasis but treatment guidelines for the management of specific psoriasis symptoms are lacking, the study authors pointed out. "While PsA, disease severity, and localization of psoriasis are often considered in of patients with psoriasis, symptoms are seldom taken into account," they wrote. "Increased attention [to] such symptoms by physicians may be warranted to further improve management of patients with psoriasis in clinical practice. Additional measures capturing joint symptoms like the should be implemented in daily management of patients with psoriasis."

The analysis also showed that patients with PsA had a higher use of opioids and other analgesics compared with those without PsA (22.7% versus 14.2%, respectively), a finding that runs contrary to previous reports. The presence of more patients with PsA in the current study (21.1% vs. 8.7%) could partially account for this, Loft and colleagues suggested.

The negative impact of psoriasis on quality of life is often dependent on , and in the Danish Skin Cohort, this was rated according to self-reported body surface area (BSA). The impact of psoriasis on patients' quality of life was measured using the (DLQI) and general health was assessed with the (EQ-5D-5L) to measure mobility, self-care, usual activities, pain/discomfort and anxiety/depression.

The analysis showed that the presence of PsA, itch, skin pain, and/or joint pain in patients with psoriasis was associated with worse general health compared with the general population. Although general health across all psoriasis severities was also significantly worse in patients with psoriasis and PsA compared with those without PsA, joint pain had the highest impact. Similarly, symptoms originating from the skin and joints were associated with an increased risk of reporting any problems in all the five EQ-5D-5L domain. Again, the strongest association was with joint pain.

"This underscores the importance of joint pain which might not be examined in all patients as routine measures like BSA, PASI [Psoriasis Area and Severity Index], or DLQI does not contain joint symptoms," the study authors said.

In the following interview, Loft, who is also with the Copenhagen Research Group for Inflammatory Skin at Copenhagen University Hospital - Herlev and Gentofte Hospital, in Hellerup, discussed the impact of different psoriasis symptoms on general health and quality of life.

What led you to undertake this study?

Loft: From previous studies, we know that patients with psoriasis have a higher use of analgesics than the general population but the reason for this is not well described.

Did any of your findings come as a surprise?

Loft: Yes. We expected patients with psoriasis to have a higher use of analgesics compared with the general population, but we expected this to be driven by both skin symptoms and joint pain and not just joint pain. We found that joint pain was associated with the use of analgesics as well as impaired general health whereas skin symptoms appeared to be associated with a worse quality of life than affected body surface.

What are the implications of your findings for clinical practice?

Loft: The most straightforward clinical implication is that we as physicians treating patients with psoriasis need to be aware of symptoms, including those originating in both joint and skin. In patients for whom symptoms are the most crucial aspect of their disease, treatment proven to be effective for managing these symptoms should be considered.

Is there an association between skin pain and joint pain? If so, what are the implications for improved pain control?

Loft: Patients with skin pain more often report joint pain as well. However, the correlation between skin pain and joint pain is weak and it is important to assess both as the absence of one does not necessarily exclude the other.