key: cord-0728969-4emzb2e9
authors: Kuang, Yehong; Shen, Minxue; Wang, Qiaolin; Xiao, Yi; Lv, Chengzhi; Luo, Yan; Zhu, Wu; Chen, Xiang
title: Association of outdoor activity restriction and income loss with patient-reported outcomes of psoriasis during the COVID-19 pandemic: A web-based survey
date: 2020-05-11
journal: J Am Acad Dermatol
DOI: 10.1016/j.jaad.2020.05.018
sha: 26edde4df05d36b28e97e2c0263527b9b9ed178c
doc_id: 728969
cord_uid: 4emzb2e9

nan

To the editor, Under the circumstances of the COVID-19 epidemic, patients with psoriasis or other chronic diseases have been confronted with limited accessibility to healthcare and medicine. Some underwent income loss or unemployment, which placed them at additional risks of adverse health outcomes. 1 The impacts of COVID-19 varied across subgroups of people, and we used outdoor activity restriction and loss of income as the proxy measures of the impacts.

We investigated the associations of these impacts with the patient-reported outcomes of psoriasis through a web-based survey in China between 25 Feb 2020 and 6 Mar 2020.

Outdoor activity restriction was categorized as unaffected, restricted, and quarantined.

Loss of income was categorized as complete loss, reduced, and unaffected. The primary outcome was the exacerbation of disease, determined by the Global Rating of Change (GRC).

Secondary outcomes included perceived stress (visual analogue scale), 2 symptoms of anxiety (2-item Generalized Anxiety Disorder) and depression (2-item Patient Health Questionnaire), adherence to treatment, and healthcare utilization. Covariates included gender, age, educational level, annual income, marital status, type of psoriasis, course of disease, body surface area of lesions, and comorbidities. Details of the measures are provided in supplementary file S1. The data were analyzed with R version 3.5.2. Multivariable logistic regression was used to estimate the associations with adjustments. The effect size was presented as adjusted odds ratio (aOR) and 95% confidence interval (CI). P<0.05 was considered statistically significant.

A total of 926 valid questionnaires was collected. One reported confirmed infection with COVID-19. The mean age of the patients was 33.1±12.2 years, and 36.9% were female. The characteristics of participants are shown in supplementary file S2. A total of 405 (43.7%) reported moderate-to-much exacerbation of psoriasis. After adjustments, outdoor activity restriction was positively associated with the exacerbation of psoriasis, stress, and symptoms of anxiety and depression in a dose-response manner, but was not associated with nonadherence (Table 1) . Similarly, income loss was associated with the exacerbation of psoriasis, stress, and symptoms of anxiety and depression (Table 2) . Differently, income loss was significantly associated with nonadherence to treatment, but was not associated with healthcare utilization. To further determine the independent factors, stepwise regression was 4 conducted, and we found that nonadherence to treatment (aOR=3.69; 95%CI: 2.67-5.18), stress (aOR=1.17; 95%CI: 1.11-1.23), quarantine (aOR=2.05; 95%CI: 1.33-3.18), and income loss (aOR=1.51; 95%CI: 1.06-2.15) were independently associated with the exacerbation of psoriasis.

Loss of income and work-related benefits experienced by the unemployed consequently lead to impaired health outcomes, 3 through mechanisms involving unhealthy coping behaviors and increased psychological distress. 4 This hypothesis is supported by our finding that nonadherence behavior (68.5%) and perceived stress were independently associated with both income loss and exacerbation of psoriasis. Isolation and temporarily closed outpatient service further limited the patients' accessibility to healthcare, especially for those who were not familiar with or accessible to teledermatology, resulting in discontinued treatment and deteriorated condition. 5 In conclusion, telemedicine and supply of drug in addition to mental health intervention are needed for patients with psoriasis to improve their health outcomes. 

Health and unemployment

Validity of occupational stress assessment using a visual analogue scale

Connections between unemployment insurance, poverty and health: a systematic review

Unemployment and subsequent depression: A mediation analysis using the parametric G-formula

Drug utilization patterns and adherence in patients on systemic medications for the treatment of psoriasis: A retrospective, comparative cohort study