BJD G E N E R A L D E R M A TO L O GY British Journal of Dermatology Reversibility of alexithymia with effective treatment of moderate-to-severe psoriasis: longitudinal data from EPIDEPSO* F. Sampogna iD ,1 L. Puig iD ,2 P. Spuls,3 G. Girolomoni,4 M.A. Radtke,5 B. Kirby,6 M. Brunori,7 P. Bergmans,8 P. Smirnov,9 J. Rundle,10 A. Castiglia,11 F. Lavie7 and C. Paul iD 12 1 Clinical Epidemiology Unit, Dermatological Hospital IDI-IRCCS FLMM, Rome, Italy 2 Universitat Autonoma de Barcelona, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain 3 Department of Dermatology, University of Amsterdam, Amsterdam, the Netherlands 4 University of Verona, Verona, Italy 5 Universit€atsklinikum Hamburg-Eppendorf, Hamburg, Germany 6 St Vincent’s University Hospital, Dublin, Ireland 7 Janssen-Cilag, Paris, France 8 Janssen-Cilag BV, Breda, the Netherlands 9 Janssen Pharmaceutica NV, Moscow, Russia 10 Janssen-Cilag Ltd, High Wycombe, U.K. 11 Janssen Cilag SpA, Cologno Monzese, Italy 12 Toulouse University and CHU H^opital Larrey, Toulouse, France Linked Comment: Misery. Br J Dermatol 2019; 180:261. Summary Correspondence Background Alexithymia refers to difficulty in identifying and expressing emotions. Carle Paul. Alexithymia is associated with high burden of disease in patients with psoriasis. E-mail: paul.c@chu-toulouse.fr Objectives To investigate whether alexithymia was reversible in patients with psori- asis following real-life therapeutic intervention. Accepted for publication 26 September 2018 Methods The Epidemiological Study in Patients with Recently Diagnosed Psoriasis (EPIDEPSO; NCT01964443) was a 1-year multicentre observational study investi- Funding sources gating the prevalence of alexithymia and other psychosocial comorbidities in This study was funded by Janssen Pharmaceutica patients with psoriasis with ≤ 10 years’ disease duration and eligible for systemic NV. treatment. Alexithymia was assessed using the Toronto Alexithymia Scale (TAS- 20) at baseline, 6 months and 1 year. Conflicts of interest Results There was a statistically significant decrease in the prevalence of alexithymia C.P., L.P., P. Spuls, G.G. and B.K. have been investigators and consultants for Janssen Pharma- in the follow-up cohort, from 267% at baseline to 212% at 6 months and ceutica. F.S. and M.A.R. have been consultants for 188% at 1 year. More than half of the patients (n = 77, 538%) who were Janssen Pharmaceutica. P.B., P. Smirnov, M.B., alexithymic at baseline experienced reversion of their alexithymia. Reversion of A.C. and F.L. were employees of Janssen Pharma- alexithymia was higher in patients who reached a high level of disease control, ceutica at the time of the study. defined as ≥ 75% or ≥ 90% improvement in Psoriasis Area and Severity Index. *Plain language summary available online Reversion of alexithymia was associated with dramatic improvement in quality of life, anxiety and depression. Moreover, hazardous alcohol use, highly prevalent in DOI 10.1111/bjd.17259 patients with alexithymia, was reduced almost threefold at 1 year. Conclusions Alexithymia and associated high disease burden may be reversible in patients with effective treatment of psoriasis. Proactive recognition of patients who are unable to identify and express their feelings is important. What’s already known about this topic? • Alexithymia, the inability to identify and express emotions, is highly prevalent in patients with psoriasis. • Patients with alexithymia have a high disease burden, with impaired quality of life, anxiety and depression. © 2018 British Association of Dermatologists British Journal of Dermatology (2019) 180, pp397–403 397 398 Alexithymia reversion in psoriasis, F. Sampogna et al. What does this study add? • Alexithymia may be reversible in patients with psoriasis. • Higher psoriasis clearance is associated with a lower prevalence of alexithymia at 1 year. • Anxiety, depression and harmful alcohol use are reduced in patients who have a reversion in alexithymia. Alexithymia refers to a difficulty in identifying and expressing with a diagnosis of plaque psoriasis from outpatient dermato- emotions.1 People with alexithymia have a reduced ability to logical clinics in 61 centres in 13 countries: Austria, Belgium, connect with their feelings and to recognize those of others. France, Greece, Ireland, Israel, Italy, the Netherlands, Norway, Difficulty in identifying and expressing emotions has been Russia, South Africa, Spain and the U.K. Included patients associated with reduced social skills and isolation. A high were adults with psoriasis with a duration of < 10 years, eli- prevalence of alexithymia has been reported in patients with gible for phototherapy or systemic therapy. The study design chronic inflammatory diseases, such as ulcerative colitis, and the cross-sectional baseline analysis have been reported asthma and rheumatoid arthritis.2 previously.7 Patients were included and followed up at We and others have investigated the prevalence of 6 months and 1 year. The severity of psoriasis was assessed alexithymia in adult patients with psoriasis. The observed using the static Physician’s Global Assessment (PGA),11 scored prevalence of alexithymia in patients with psoriasis ranges from 0 (cleared) to 5 (severe), and the Psoriasis Area and between 156%3 and around 33%.4–6 Our study7 showed that Severity Index (PASI).12 patients with psoriasis with difficulty in identifying and expressing emotions were characterized by high psoriasis bur- Evaluation of alexithymia den, including markedly reduced quality of life, high preva- lence of anxiety and depression, and high risk of alcohol Alexithymia was defined by a score ≥ 61 in the 20-item Tor- dependency. In addition, patients with alexithymia had low onto Alexithymia Scale (TAS-20),13,14 a self-administered work productivity and a high risk of unemployment. questionnaire evaluating the three components of alexithymia: An important question concerning alexithymia is whether it difficulty in identifying feelings (seven questions), difficulty in is reversible or whether it is a stable personality trait that can- describing feelings (five questions) and externally oriented not be modified by intervention. Some studies have shown thinking (eight questions). that alexithymia is stable over time in the general popula- tion,8,9 while studies in patients with substance-abuse disor- Patient-reported outcomes ders have shown that alexithymia may disappear.10 In psoriasis, published studies are cross-sectional and have not Health-related quality of life was measured using the addressed the issue of alexithymia reversibility. Dermatology Life Quality Index (DLQI).15 Anxiety and The aim of the Epidemiological Study in Patients with depression were assessed using the Hospital Anxiety Recently Diagnosed Psoriasis (EPIDEPSO) longitudinal study and Depression Scale (HADS),16,17 a 14-item scale with was to investigate whether reduction of alexithymia may be seven of the items relating to anxiety (HADS-A) and seven associated with psoriasis therapeutic intervention. The ratio- relating to depression (HADS-D). Patients were categorized nale for reduction of alexithymia with clearance of psoriasis is as noncases (score 0–7), doubtful cases (8–10) or cases based on the concept that patients with psoriasis may reduce (11–21). their perception of emotion as a defence mechanism against The self-reported Alcohol Use Disorders Identification Test stigmatization induced by skin lesions. By clearing psoriasis (AUDIT) questionnaire18 was used to screen for excessive lesions, it may be hypothesized that this defence mechanism drinking. It consists of 10 questions, and a score ≥ 8 is associ- disappears. Patients described in the cross-sectional publication ated with hazardous drinking and risk of alcohol dependency. of the EPIDEPSO study7 were followed up for 1 year to evalu- To assess impairment in work and activities, the Work Pro- ate the changes in alexithymia and psoriasis burden following ductivity and Activity Impairment Questionnaire: Psoriasis real-life therapeutic intervention. (WPAI:PSO)19,20 was used. It gives four scores: absenteeism (work time missed), presenteeism (impairment at work and reduced on-the-job effectiveness), work productivity loss Patients and methods (overall work impairment; absenteeism plus presenteeism) and activity impairment. The WPAI:PSO outcomes were Study design and population expressed as impairment percentages, with higher numbers EPIDEPSO is an observational, multicentre study with 1-year indicating greater impairment and less productivity (i.e. worse follow-up. The study population included consecutive patients outcomes). British Journal of Dermatology (2019) 180, pp397–403 © 2018 British Association of Dermatologists Alexithymia reversion in psoriasis, F. Sampogna et al. 399 212% (95% CI 178–250, n = 515) at 6 months and 188% Statistical analyses (95% CI 153–227, n = 458) at 1 year. The decrease in The sample size was based on a clinically acceptable 95% con- alexithymia prevalence was significant at each time point com- fidence interval (CI) of the prevalence of alexithymia in a sub- pared with baseline (month 6, P = 00032; month 12, group of 160 patients who had psoriasis for < 5 years P < 0001; LOCF end point P = 0001; McNemar’s test). At (estimated to be around 20% of the total sample of 800 the end of the study (LOCF end point) more than half of the patients).7 patients (n = 77, 538%) who were alexithymic at baseline The prevalence rates of alexithymia were calculated at the became nonalexithymic. The mean percentage reduction in 6-month and 1-year follow-ups. Last observation carried for- the TAS-20 in patients who shifted from alexithymic to ward (LOCF) analysis was performed in addition to observed nonalexithymic at 12 months was 27% (95% CI 306 to case analysis. The prevalence of alexithymia was compared in 24). Calculation of reliable-change indices for this group subgroups of patients, depending on demographic characteris- revealed that the change in TAS-20 score was reliable in 60% tics, clinical variables and patient-reported outcomes, using of the cases. Fisher’s exact test for independent categorical variables, McNe- Of the three factors of the TAS-20, factor 1, difficulty in mar’s test for dependent categorical variables and Wilcoxon’s identifying feelings, displayed the highest mean percentage two-sample test (or t-test) for continuous variables. A P-value reduction at 12 months ( 425%, 95% CI 476 to 373). < 005 was considered statistically significant. TAS-20 data at Factor 2, difficulty in describing feelings, showed a mean baseline and the LOCF end point were used to calculate reli- 286% reduction at 12 months (95% CI 335 to 236). able-change indices.21 For the measurement scales, such as the Factor 3, the externally oriented thinking subscale, showed TAS-20, DLQI, HADS, AUDIT and WPAI:PSO, the scores were the lowest mean percentage reduction ( 76%, 95% CI calculated and missing items were handled according to the 116 to 36). When looking at individual items of the recommendations of the developers of the scales. TAS-20, the largest changes in patients who shifted to nonalexithymic were seen in questions relating to identifying and describing feelings (Table S1; see Supporting Informa- Results tion). Among the patients who had no or possible alexithymia at baseline, 36 (92%) had shifted towards alexithymia. Study population The prevalence of alexithymia at baseline and at the end of Out of 670 patients included at baseline, LOCF data for 543 the study, according to demographic and clinical variables, is patients (810%) were available (follow-up analysis set). Six- shown in Table S2 (see Supporting Information). The preva- month follow-up data were available for 522 individuals lence of alexithymia decreased in almost all patient categories. (779%) and 1-year data for 467 (697%). The TAS-20 ques- The decrease in alexithymia was higher in patients aged tionnaire was completed by 536 patients at one or more of the ≤ 40 years than in those aged > 40 years, in patients with a follow-up visits, representing the follow-up analysis population. disease duration > 1 year from the first symptom or the first The demographic and clinical characteristics of the 543 diagnosis compared with duration ≤ 1 year, and in patients patients with follow-up data were comparable with those of with psoriasis of the face/neck or hands compared with the 127 patients who were not analysed, except for a slightly patients who did not have psoriasis in those sites. For patients higher mean age in the follow-up analysis set: 445  161 with PASI > 10 at baseline, the prevalence of alexithymia vs. 405  163 years. decreased from 336% at baseline to 168% at the end point, while for patients with baseline PASI ≤ 10 the prevalence remained approximately the same. Psoriasis treatment in the cohort In total, 496% of patients were treated with phototherapy and Relationship between change in alexithymia prevalence 504% received a systemic psoriasis treatment. The most fre- and change in psoriasis severity quently used systemic treatment in the cohort was methotrex- ate (48%), followed by ciclosporin (26%). Biological agents The mean  SD PASI improved from 102  69 at baseline were prescribed in 14% of patients, with approximately half of to 37  53 at the LOCF end point. At the LOCF end point, the patients receiving ustekinumab and half receiving a tumour 305% of patients reached ≥ 90% improvement in PASI (PASI necrosis factor-a antagonist. Acitretin and fumaric acid were 90) and 463% reached PASI 75. The improvement in PASI used by 79% and 35% of patients, respectively. was significantly higher in patients with alexithymia at base- line than in the other group (423% vs. 263% reached PASI 90, P < 0001). Among patients who reached an outcome of Change in alexithymia prevalence during the 1-year PASI 75 or PASI 90, the prevalence of alexithymia significantly follow-up and relationship with demographic and decreased (Table S2; see Supporting Information). For exam- psoriasis clinical characteristics ple, among patients who reached PASI 90, only 125% had The overall prevalence of alexithymia in the follow-up set at alexithymia at follow-up. Similar results were obtained for the baseline was 267% (95% CI 230–306). The prevalence was PGA: only 156% of patients with PGA ≤ 1 at follow-up had © 2018 British Association of Dermatologists British Journal of Dermatology (2019) 180, pp397–403 400 Alexithymia reversion in psoriasis, F. Sampogna et al. alexithymia, while the prevalence of alexithymia in patients from 278% to 103% for the no or possible alexithymia with PASI > 10 at follow-up was 415%. group. The mean HADS-A and HADS-D scores improved in the follow-up cohort from 77  43 and 54  42, respec- Change in alexithymia prevalence during the 1-year tively, at baseline to 61  44 and 43  41 at follow-up. follow-up and relationship with anxiety, depression and HADS-A and HADS-D improvement was significantly higher alcohol dependency in patients with baseline alexithymia than in patients with no Table 1 describes the prevalence of alexithymia at baseline and or possible alexithymia at baseline: HADS-A: –35  52 vs. at the end of the study in patients categorized by the presence –099  33, respectively; and HADS-D: –30  50 vs. or absence of anxiety, depression and hazardous alcohol use. –039  32, respectively (both P < 0001, Wilcoxon two- As shown in our previous report,7 the prevalence of sample test). alexithymia at baseline was significantly higher in patients with Considering the presence of depression and anxiety, 295% anxiety, depression and hazardous alcohol use than in the of patients reported depression at baseline and 190% reported others. During the 12-month follow-up, a striking decrease in depression at the LOCF end point. In the group of patients alexithymia prevalence was observed in patients with depres- who were alexithymic at baseline, the prevalence of depres- sion and/or anxiety at baseline. Also, patients with an AUDIT sion decreased from 619% to 324%, while in the group with score ≥ 8 at baseline had almost threefold reduction in no or possible alexithymia that prevalence decreased from alexithymia prevalence at the end of the study. 176% to 141%. The rate of anxiety was 483% at baseline and 309% at the LOCF end point (change from 786% to 414% in the alexithymia group and from 370% to 270% in Evolution of work productivity patients with no alexithymia at baseline). WPAI:PSO showed a decrease in the mean overall work pro- Hazardous drinking, as defined by an AUDIT score ≥ 8, ductivity loss from 218  299 at baseline to 113  207 at was more frequent at baseline in patients who were the end point. Activity impairment at baseline had a mean alexithymic (30%) than in patients with no or possible score of 260  289; at follow-up it decreased to alexithymia (13%). At the end of the study, the percentage of 127  220. The WPAI absenteeism mean score was patients with an AUDIT score ≥ 8 was reduced more than 79  225 at baseline and 27  115 at the end point. twofold in patients who were alexithymic at baseline (from 303% to 127%). Changes in patient-reported outcomes were more dramatic in patients with alexithymia Characteristics of patients with alexithymia who became nonalexithymic at follow-up The changes from baseline to the end of the study in depres- sion, anxiety, quality of life and hazardous drinking, accord- Based on the alexithymia status at baseline and the end point, ing to alexithymic status at baseline, are graphically four groups of patients can be identified: patients who did not represented in Figure 1. The mean  SD DLQI score reduced change their alexithymic or nonalexithymic status, and those from 90  67 at baseline to 45  55 at follow-up. At who did change their status. Figure 2 shows the difference baseline, patients with alexithymia reported worse quality of between the follow-up and baseline mean scores for PASI, life, with a mean DLQI score of 125  70 compared with DLQI, HADS-A, HADS-D and AUDIT in these four groups. The 78  61 in patients with no or possible alexithymia. The most striking improvement (i.e. a decrease in the scores) was number of patients with a DLQI score > 10 decreased from observed in the group of patients with alexithymia who 560% at baseline to 220% for the alexithymia group, and became nonalexithymic at follow-up. Table 1 Prevalence of alexithymia at baseline and at the end of the study according to patient-reported outcomes (n = 536) Total, n (%) Alexithymia at baselinea Alexithymia at end of studya Baseline anxiety (HADS-A) Yes 250 (483) 110, 440 (378–504) 73, 292 (236–353) No 268 (517) 30, 112 (77–156) 28, 104 (71–147) Baseline depression (HADS-D) Yes 152 (295) 86, 566 (483–646) 52, 342 (267–423) No 363 (705) 53, 146 (111–187) 45, 124 (92–162) Baseline AUDIT score ≥ 8 Yes 94 (176) 43, 46 (354–563) 15, 16 (92–250) No 439 (824) 99, 226 (187–268) 86, 196 (160–236) HADS, Hospital Anxiety and Depression Scale (A, anxiety; D, depression); AUDIT, Alcohol Use Disorders Identification Test. aData are given as n, % (95% confidence interval). British Journal of Dermatology (2019) 180, pp397–403 © 2018 British Association of Dermatologists Alexithymia reversion in psoriasis, F. Sampogna et al. 401 90 80 70 60 50 % 40 30 20 10 0 Baseline Follow-up Baseline Follow-up Baseline Follow-up Baseline Follow-up DLQI >10 Depression Anxiety AUDIT ≥ 8 Alexithymia at baseline No alexithymia at baseline Fig 1. Percentage of patients with depression, anxiety, Dermatology Life Quality Index (DLQI) > 10 and Alcohol Use Disorders Identification Test (AUDIT) ≥ 8 at baseline and at follow-up (last observation carried forward), according to alexithymia status at baseline. Table 2 compares the level of psoriasis severity improve- treatment for psoriasis. We observed a strong association ment, quality-of-life improvement and psychological burden between reversibility of alexithymia and tight control of psori- in patients with alexithymia who had a reversion in alex- asis. Patients who reached PASI 90 after 1 year of treatment, ithymia compared with patients who remained alexithymic. and patients who were cleared or almost clear of psoriasis at Patients who became nonalexithymic had a much better con- follow-up, showed the highest reduction in alexithymia trol of their psoriasis at the end of the study, with a higher prevalence compared with patients who had lower clinical chance of reaching PASI 90 than patients who stayed alex- improvement. ithymic. Similarly, the prevalences of anxiety, depression and The reversibility of alexithymia in psoriasis supports the hazardous alcohol use at 1 year were much lower in patients concept that two forms of alexithymia exist – a ‘trait’ and a who had a reversion in alexithymia. ‘state’23 – the first being a personality characteristic and the latter being an acquired state that may be modified by a thera- peutic intervention or a change in psychological status. Psoria- Discussion sis is a chronic visible disease associated with a high level of The 1-year follow-up of the EPIDEPSO study shows that the stigmatization and has a profound effect on affective and prevalence of alexithymia in patients with psoriasis treated social well-being. Kleyn et al.24 have shown that patients with with systemic agents in real-life conditions decreased signifi- psoriasis shut down their neural and cognitive responses to cantly. This reduction was especially evident in patients certain emotions probably as a protective measure to cope younger than 40 years, in patients with a disease duration of with the permanent social stigmatization. This may explain > 1 year, in patients with psoriasis that was localized to the the low emotional awareness identified in patients with psori- face/neck or hands, and in patients who reached a high level asis and the high prevalence of alexithymia, which may be of disease control, defined by PASI 75 or PASI 90. The considered a defence mechanism against stigmatization.7,25 reversibility of alexithymia was associated with a dramatic We and others have shown that alexithymia identifies a improvement in quality of life, anxiety and depression. More- group of patients with psoriasis with severely impaired qual- over, hazardous alcohol use, which was highly prevalent in ity of life, high risk of depression and anxiety, high alcohol patients with alexithymia, was reduced almost threefold at dependency and reduced work productivity. Here we show 1 year, the reduction being more dramatic in patients who that reversibility of alexithymia is associated with a dramatic reversed their alexithymia. improvement in quality of life, reduction of depression and The reversibility of alexithymia shown in psoriasis is in line anxiety, and improvement in work productivity. Interestingly, with the notion that alexithymia may be partly modifiable hazardous alcohol use and alcohol dependency, as measured with psychological interventions.22 In the present study, the by AUDIT, were very prevalent in the EPIDEPSO cohort.7 therapeutic intervention consisted of real-life systemic High alcohol use has been associated with psoriasis,26 and © 2018 British Association of Dermatologists British Journal of Dermatology (2019) 180, pp397–403 402 Alexithymia reversion in psoriasis, F. Sampogna et al. 2.00 PASI DLQI HADS-A HADS-D AUDIT 0.00 -2.00 -4.00 -6.00 -8.00 -10.00 -12.00 ALX-ALX ALX-NO ALX NO ALX-ALX NO ALX-NO ALX Fig 2. Difference between the follow-up and baseline scores according to change in alexithymia status. ALX-ALX, alexithymia at baseline and alexithymia at end point; ALX-NO ALX, alexithymia at baseline and no alexithymia at end point; NO ALX-ALX, no alexithymia at baseline and alexithymia at end point; NO ALX-NO ALX, no alexithymia at baseline and no alexithymia at end point. PASI, Psoriasis Area and Severity Index; DLQI, Dermatology Life Quality Index; HADS, Hospital Anxiety and Depression Scale (A, anxiety; D, depression); AUDIT, Alcohol Use Disorders Identification Test. Negative changes represent improvement for all scales. Table 2 Differences in outcomes for patients with alexithymia who To our knowledge, this is the first longitudinal study evalu- became nonalexithymic at the end of the study vs. the patients who ating the change in the ability of patients with psoriasis to remained alexithymic identify and describe emotions during treatment. In fact, the existing studies were cross-sectional.3–6 Only a longitudinal Remained Became design may allow evaluation of changes over time and evalua- alexithymic nonalexithymic (n = 66), % (n = 77), % tion of the complex association between alexithymia, disease End point (95% CI) (95% CI) severity and disease burden. According to the results of the present study, there is at least a part of alexithymia that is PASI < 3 50 (37–63) 75 (64–84) PASI 75 36 (24–49) 70 (58–80) reversible upon clinical improvement of psoriasis according to PASI 90 21 (12–34) 59 (47–70) the TAS-20 questionnaire, a validated instrument to measure DLQI 0/1 20 (11–31) 53 (41–65) alexithymia. It has been shown that improvement in clinical Anxiety (HADS-A > 8) 59 (46–71) 27 (17–38) severity and symptoms of psoriasis is associated with a Depression (HADS-D > 8) 52 (39–64) 16 (9–26) decreased frequency of psychiatric disturbance, such as depres- AUDIT > 8 20 (11–31) 7 (2–15) sion and anxiety.28 CI, confidence interval; PASI, Psoriasis Area and Severity Index; There are some limitations in our study. Firstly, as the study PASI 75, ≥ 75% improvement in PASI; DLQI, Dermatology Life concerns patients with a short disease duration, it is not possi- Quality Index; HADS, Hospital Anxiety and Depression Scale (A, ble to know whether the results apply to patients with longer anxiety; D, depression); AUDIT, Alcohol Use Disorders Identifi- disease duration. Secondly, even though we show a close asso- cation Test. ciation between the degree of psoriasis clearance and reversion of alexithymia, causality cannot be established due to the observational nature of the study. Thirdly, the relationship recently, increased alcohol-related mortality has been shown between alexithymia and depression should be interpreted in patients with psoriasis.27 Thus the reduction of hazardous with caution as the HADS, used in this study, has shown limi- alcohol use observed in the cohort, especially in patients tations in the ability to diagnose depression, and its diagnostic who had a reversion of alexithymia, is of particular impor- accuracy is currently under scrutiny.29 Finally, the changes tance for prevention. observed in the TAS-20 were variable across patients, and in a British Journal of Dermatology (2019) 180, pp397–403 © 2018 British Association of Dermatologists Alexithymia reversion in psoriasis, F. Sampogna et al. 403 minority of them the changes might not be clinically 14 Bagby RM, Taylor GJ, Parker JD. The twenty-item Toronto Alex- significant. ithymia Scale – II. Convergent, discriminant, and concurrent valid- In conclusion, this study shows that the inability of patients ity. J Psychosom Res 1994; 38:33–40. 15 Finlay AY, Khan GK. Dermatology Life Quality Index (DLQI) – a to identify and describe emotions may be reversible in patients simple practical measure for routine clinical use. Clin Exp Dermatol with psoriasis. Reversion of alexithymia is associated with 1994; 19:210–16. improvement in several important domains, including quality 16 Bjelland I, Dahl AA, Haug TT, Neckelmann D. The validity of the of life, depression, anxiety, work productivity and addictive Hospital Anxiety and Depression Scale. An updated literature behaviour. Proactive recognition of patients with alexithymia, review. J Psychosom Res 2002; 52:69–77. who have high psoriasis burden but are unable to express their 17 Zigmond AS, Snaith RP. The Hospital Anxiety and Depression feelings, may help to propose a therapeutic plan that includes Scale. 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