Aims As part of a larger study to estimate the global burden of disease and injury attributable to alcohol: to evaluate the evidence for a causal impact of average volume of alcohol consumption and pattern of drinking on diseases and injuries; to quantify relationships identified as causal based on published meta-analyses; to separate the impact on mortality versus morbidity where possible; and to assess the impact of the quality of alcohol on burden of disease. Methods Systematic literature reviews were used to identify alcohol-related diseases, birth complications and injuries using standard epidemiological criteria to determine causality. The extent of the risk relations was taken from meta-analyses. Results Evidence of a causal impact of average volume of alcohol consumption was found for the following major diseases: tuberculosis, mouth, nasopharynx, other pharynx and oropharynx cancer, oesophageal cancer, colon and rectum cancer, liver cancer, female breast cancer, diabetes mellitus, alcohol use disorders, unipolar depressive disorders, epilepsy, hypertensive heart disease, ischaemic heart disease (IHD), ischaemic and haemorrhagic stroke, conduction disorders and other dysrhythmias, lower respiratory infections (pneumonia), cirrhosis of the liver, preterm birth complications and fetal alcohol syndrome. Dose-response relationships could be quantified for all disease categories except for depressive disorders, with the relative risk increasing with increased level of alcohol consumption for most diseases. Both average volume and drinking pattern were linked causally to IHD, fetal alcohol syndrome and unintentional and intentional injuries. For IHD, ischaemic stroke and diabetes mellitus beneficial effects were observed for patterns of light to moderate drinking without heavy drinking occasions (as defined by 60+ g pure alcohol per day). For several disease and injury categories, the effects were stronger on mortality compared to morbidity. There was insufficient evidence to establish whether quality of alcohol had a major impact on disease burden. Conclusions Overall, these findings indicate that alcohol impacts many disease outcomes causally, both chronic and acute, and injuries. In addition, a pattern of heavy episodic drinking increases risk for some disease and all injury outcomes. Future studies need to address a number of methodological issues, especially the differential role of average volume versus drinking pattern, in order to obtain more accurate risk estimates and to understand more clearly the nature of alcohol-disease relationships.

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The relation between different dimensions of alcohol consumption and burden of disease - an overview

Psoriasis is associated with significant physical and psychological burden affecting all facets of a patient's life--relationships, social activities, work and emotional wellbeing. The cumulative effect of this disability may be self-perpetuating social disconnection and failure to achieve a 'full life potential' in some patients. Health-related quality of life studies have quantified the burden of psoriasis providing predominantly cross-sectional data and point-in-time images of patients' lives rather than assessing the possible cumulative disability over a patient's lifetime. However, social and economic outcomes indicate there are likely negative impacts that accumulate over time. To capture the cumulative effect of psoriasis and its associated co-morbidities and stigma over a patient's life course, we propose the concept of 'Cumulative Life Course Impairment' (CLCI). CLCI results from an interaction between (A) the burden of stigmatization, and physical and psychological co-morbidities and (B) coping strategies and external factors. Several key aspects of the CLCI concept are supported by data similar to that used in health-related quality of life assessments. Future research should focus on (i) establishing key components of CLCI and determining the mechanisms of impairment through longitudinal or retrospective case-control studies, and (ii) assessing factors that put patients at increased risk of developing CLCI. In the future, this concept may lead to a better understanding of the overall impact of psoriasis, help identify more vulnerable patients, and facilitate more appropriate treatment decisions or earlier referrals. To our knowledge, this is a first attempt to apply and develop concepts from 'Life Course Epidemiology' to psoriasis research.

Psoriasis: is the impairment to a patient's life cumulative?

Summary

Background The safety of topical therapies for atopic dermatitis (AD), a common and morbid disease, has recently been the focus of increased scrutiny, adding confusion as how best to manage these patients.



Objectives  The objective of these systematic reviews was to determine the safety of topical therapies for AD.



Methods  Databases searched included: OVID Medline, Medline In-Process and Other Non-Indexed Citations, Embase, and the Cochrane Central Register of Controlled Trials. In addition to the articles identified by this search, investigators were also referred to a list of links (most recently updated 25 September 2005) to recent Food and Drug Administration (FDA) studies, reports and meetings regarding the topical calcineurin inhibitors for further potential references. Only fully published papers available in English and data obtained from FDA sites were included. Furthermore, the criteria for inclusion and exclusion for each systematic review were further evaluated at a meeting of all of the content and evidence-based medicine experts participating in this process and alteration of the inclusion criteria was done at that time when it was felt necessary to avoid inclusion of lower-quality data in the review. Qualitative review of the abstracted data was performed and reviewed at a meeting of all of the content and evidence-based medicine experts.



Results  While systemic exposure to these topical agents does occur, physiological changes appear to be uncommon and systemic complications rare and have only been found with use of topical corticosteroids.



Conclusions  Based on the data that are available the overall safety of AD therapies appears to be good with the only documented systemic side-effects of therapy those occasionally seen with use of topical corticosteroids.

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A systematic review of the safety of topical therapies for atopic dermatitis.

Immune-mediated inflammatory diseases (IMID) present a group of common and highly disabling chronic conditions that share inflammatory pathways. Several incidence and prevalence studies of IMID during the past decades have reported a considerable variation of the disease occurrence among different populations. Overall, the estimated prevalence of IMID in Western society is 5%-7%. This article provides an overview of studies of the incidence, prevalence, natural history, and comorbidities of IMID.

https://www.jrheum.org/content/jrheumsupp/85/2.full.pdf

Epidemiology of Immune-Mediated Inflammatory Diseases: Incidence, Prevalence, Natural History, and Comorbidities

Psoriasis is a chronic disease that can negatively impact many aspects of quality of life. Patients with psoriasis may suffer from pain and discomfort from the disease as well as psychological and social difficulties including stigmatization, embarrassment, and social inhibition. Anxiety, depression, smoking, and alcohol abuse have been found to have a higher prevalence among psoriasis patients than healthy controls. These comorbidities have also been found to have a directly negative impact on psoriasis. Awareness of the relationship between psoriasis, psychiatric disorders, and substance abuse is important for dermatologists, as these comorbidities can lead to poor compliance and treatment outcomes.

Psoriasis: depression, anxiety, smoking, and drinking habits

BACKGROUND: Psoriasis has been associated with excessive alcohol consumption and psychological distress. OBJECTIVES: To investigate the level of alcohol use in a psoriasis population and to determine whether alcohol consumption is linked to psychological distress in patients with psoriasis. METHODS: Ninety-five patients with chronic plaque psoriasis completed validated questionnaires designed to assess psychological distress, current and past alcohol consumption and self-reported physical severity of psoriasis. RESULTS: Using different measures of alcohol consumption, between 17% and 30% of patients were classified as having difficulties with alcohol. Thirteen per cent and 18% of patients with psoriasis believed that they had a current or past drinking problem, respectively. There was a modest but significant association between levels of anxiety and depression and weekly alcohol consumption (r = 0.29, P < 0.01 and r = 0.24, P = 0.03, respectively). Those patients who believed that they had an alcohol problem had higher levels of anxiety (P = 0.03), depression (P < 0.01) and psoriasis-associated disability (P = 0.04). There was a modest but significant association between physical severity of psoriasis and weekly alcohol consumption (r = 0.27, P = 0.02). CONCLUSIONS: A significant minority of patients with psoriasis consumes excessive alcohol. Patients with psoriasis should be assessed for excessive alcohol use and appropriate interventions initiated. Further studies are required to investigate whether such interventions are effective in combating alcohol abuse and in improving the psychological and physical aspects of psoriasis.

Alcohol consumption and psychological distress in patients with psoriasis.

Summary
Background Psoriasis may, in some patients, be triggered and/or exacerbated by stress.

Objectives  As activation of the hypothalamic–pituitary–adrenal (HPA) axis is critical to a successful stress response we investigated this in patients with psoriasis.

Methods  Forty patients with chronic plaque psoriasis and 40 age-matched normal controls experienced three randomly presented acute psychological stressors (cognitive, emotional and social). Serial serum cortisol, pulse rate and blood pressure assessments were undertaken at baseline and following each of the stressors. Salivary cortisol samples were collected at 09·00 h on the day of testing.

Results  In control subjects there was a significant (r = 0·38; P < 0·05) correlation between pulse rate and serum cortisol level following the social performance stressor; this was not evident in the psoriasis group (r = 0·07; not significant). Patients who believed that their psoriasis was highly stress responsive had significantly lower salivary cortisol levels at baseline (P < 0·01) and lower serum cortisol levels following the social performance stressor (P = 0·016) than patients with nonstress-responsive disease who believed that stress had no impact. In contrast, there was no difference between the groups for change in pulse rate poststressor.

Conclusions  This study shows that patients with psoriasis, and in particular those whose disease appears to be stress responsive, exhibit an altered HPA response to acute social stress. The implication is that such patients may perhaps be primed to flares of their psoriasis. Whether this is genetically predetermined and/or a consequence of the distress of living with psoriasis remains to be determined.

D.L. Mason

Papers

Alcohol consumption and psychological distress in patients with psoriasis.

Response of the hypothalamic–pituitary–adrenal axis to psychological stress in patients with psoriasis