254 Research letters P = 0015]. The direction of association remained after adjust- ing for age, sex and ethnicity, although this was not statisti- Vaccine hesitancy and access to psoriasis care cally significant (adjusted OR 190, 95% CI 072–505) during the COVID-19 pandemic: findings from (Figure 1d). In the imputed multivariate model (fitted due to a global patient-reported cross-sectional missing demographic data), the association was stronger but survey not significant (adjusted OR 232, 95% CI 094–571). In total, 56 of 320 (175%) individuals taking standard, targeted DOI: 10.1111/bjd.21042 or combination immunosuppressants were nonadherent. Non- adherence and vaccine hesitancy were not significantly associ- DEAR EDITOR, COVID-19 vaccines protect against severe ated (adjusted OR 296, 95% CI 077–113). COVID-19 outcomes; however, many individuals remain We observed an association between disrupted access to unvaccinated.1,2 Vaccine hesitancy (delayed acceptance or psoriasis care and COVID-19 vaccine hesitancy, partly medi- refusal of vaccination despite service availability) threatens ated by confounding demographic variables. Individuals feel- public health. In the UK general population, vaccine hesi- ing disenfranchized by healthcare services were more likely to tancy is higher in women, younger people and ethnic be vaccine hesitant. In keeping with this finding, higher vac- minority groups.3,4 Individuals with psoriasis, particularly cine hesitancy in the general population is observed in those those taking systemic immunosuppressants, are prioritized for with negative experiences of healthcare and negative percep- COVID-19 vaccination.5 However, information on vaccine tions of doctors.4 Higher care expectations, sometimes seen in hesitancy and its contributing factors in patients with psoria- individuals with worse disease,8 may also be contributory. sis is scarce.6 Patients taking targeted immunosuppressants were less likely We used data from the global patient-reported PsoProtectMe to report disrupted access to care, possibly due to more fre- survey7 to explore the impact of organizational and individual quent monitoring in secondary care, which may have been factors on COVID-19 vaccine hesitancy. Data from 802 indi- prioritized during the pandemic. viduals with psoriasis from 89 countries were available (ex- A minority (8%) of our sample reported vaccine hesitancy. tracted 9 August 2021). Overall, 322 (401%) reported This finding supports current limited data on vaccine hesitancy disrupted access to psoriasis care. These individuals were among patients with psoriasis.6 In contrast to a prior report in younger [median age 44 years, interquartile range (IQR) 33– psoriasis,6 but in keeping with general population trends,4 56 vs. 54 years, IQR 42–64] and more likely to be of non- hesitancy was more prominent among younger people. Our white ethnicity (138% vs. 102%) than those reporting no study was conducted after the COVID-19 vaccine rollout com- disruption. They had a shorter duration of psoriasis (median menced, addressing a limitation of studies characterizing 23 years, IQR 10–36 vs. 31 years, IQR 17–44) and more sev- intention rather than actual behaviour.6 In keeping with other ere psoriasis (61% vs. 28%). The proportion of participants studies, our findings also indicate greater hesitancy in individ- taking systemic immunosuppressants was similar between uals of nonwhite ethnicity; however, there were no differ- those with and without disrupted access to care, but a smaller ences by sex.4 proportion with disrupted care were taking targeted immuno- We are unable to directly compare our global psoriasis data- suppressants than those without disruption (72 of 131, 550% set to the general population or groups with other diseases vs. 140 of 194, 722%). due to a lack of control samples. Participants were mostly In total, 611 (809%) of 755 participants had received at from the UK, female and of white ethnicity, limiting general- least one vaccine dose; 99 (162%) reported worsened psoria- izability. Proportionally more patients reported receiving tar- sis following vaccination, with 63 describing changes within geted vs. standard immunosuppression, indicating 2 weeks. Sixty-three (83%) were vaccine hesitant. These indi- ascertainment bias. Directions of associations cannot be defini- viduals were younger (median age 36, IQR 30–50 vs. 52, IQR tively ascertained due to the cross-sectional study design. 39–63), and more likely to be of nonwhite ethnicity (20% vs. Impacts on care and/or vaccine uptake may have been under- 72%), live outside the UK (14% vs. 51%), have a numeri- estimated as individuals participating in health surveys may be cally lower body mass index (median 245 kg m2, IQR more engaged with healthcare and vaccination services. 217–283 vs. 265 kg m2, 232–309) and have a shorter PsoProtectMe was updated 1 year following its launch to disease duration (median 19 years, IQR 9–32 vs. 28 years, include COVID-19 vaccine hesitancy and questions regarding IQR 14–42) than those who were not hesitant (Figure 1a–c). access to care, hence the current sample may not be represen- They were less likely to be taking systemic immunosuppres- tative of the original larger sample.7 sants (26% vs. 453%). The most common reasons for hesi- Taken together, these data indicate that only a minority of tancy were concerns regarding side-effects, the vaccine being individuals with psoriasis have vaccine hesitancy hence our new and psoriasis worsening postvaccination. findings are promising for current and future COVID-19 vac- In an unadjusted logistic regression model, strongly agree- cine uptake. Identifying individuals who are disenfranchized ing that psoriasis care was disrupted, was associated with vac- by healthcare services and addressing their concerns regarding cine hesitancy [compared with strongly disagreeing; odds COVID-19 vaccination will help mitigate risks from the ongo- ratio (OR) 297, 95% confidence interval (CI) 123–713, ing pandemic. British Journal of Dermatology (2022) 187, pp246–273 Ó 2022 The Authors. British Journal of Dermatology published by John Wiley & Sons Ltd on behalf of British Association of Dermatologists. This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. Research letters 255 Figure 1 COVID-19 vaccine hesitancy in individuals with psoriasis: (a) overall count, (b) by age and ethnicity (age < 31 years n = 93, 31– 50 years n = 219, 51–70 years n = 261, > 70 years n = 58; white ethnicity n = 559, nonwhite ethnicity n = 70) and (c) by systemic immunosuppressant therapy (no therapy n = 406, standard therapy n = 110, targeted therapy n = 207). (d) Association between disrupted access to psoriasis care and COVID-19 vaccine hesitancy. Acknowledgments: We are extremely grateful to all the for help with translating the PsoProtectMe survey: Dr patients who have contributed to PsoProtectMe, the profes- Haleema Alfailakawi, Dr Wisam Alwan, Dr Rosa Andres sional and patient organizations who supported or promoted Ejarque, Dr Ines Barbosa, Ms Carmen Bugarin Diz, Ms PsoProtectMe, and Professor Lars Iversen, Professor Nick Rey- Katarzyna Grys, Dr Mahira Hamdy El Sayed, Mr Tran Hong nolds and Professor Joel Gelfand for their valuable input. Truong, Mr Masanori Okuse, Ms Dagmara Samselska, Ms We would like to acknowledge the following individuals Isabella Tosi and Ms Ya-Hsin Wang. Thank you to the Ó 2022 The Authors. British Journal of Dermatology British Journal of Dermatology (2022) 187, pp246–273 published by John Wiley & Sons Ltd on behalf of British Association of Dermatologists. 256 Research letters Engine Group UK for their generous creative input and Data availability: the data that support the findings of this website expertise. study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions. Katie Bechman,1 Emma S. Cook iD ,1 Nick Dand iD ,2,3 Zenas Z.N. Yiu iD ,4 Teresa Tsakok iD ,5 Freya Meynell,5 Supporting Information Bolaji Coker,6 Alexandra Vincent,6 Herve Bachelez iD ,7,8 Ines Barbosa,5 Matthew A. Brown iD ,1,6 Additional Supporting Information may be found in the online Francesca Capon iD ,2,6 Claudia R. Contreras iD ,9 version of this article at the publisher’s website: Claudia De La Cruz iD ,10 Paola Di Meglio iD ,6,11 Paolo Gisondi iD ,12 Denis Jullien iD ,13,14 Jade Kelly,4 Appendix S1 Full list of affiliations. Jo Lambert iD ,15 Camille Lancelot,16 Sinead M. Langan iD ,5,17 Kayleigh J. Mason,4,18 Helen McAteer iD ,19 Lucy Moorhead,5 Appendix S2 Funding sources. Luigi Naldi iD ,20 Sam Norton iD ,21 Lluıs Puig iD ,22 Phyllis I. Spuls iD ,23 Tiago Torres iD ,24 Dominic Urmston,19 Appendix S3 Conflicts of interest. Amber Vesty,19 Richard B. Warren iD ,4 Hoseah Waweru,16 John Weinman iD ,25 Christopher E.M. Griffiths iD ,4 Jonathan N. Barker iD ,6,11 Catherine H. Smith iD ,5,6 James B. Galloway iD ,1 Satveer K. Mahil iD 5,6 and on behalf of the PsoProtect study group Email: satveer.mahil@kcl.ac.uk Validation of the Danish version of the Quality of Life in Hand Eczema Questionnaire A full list of affiliations is provided in Appendix S1. (QOLHEQ) K.B. and E.S.C. are joint first authors. DOI: 10.1111/bjd.21041 J.B.G. and S.K.M. are joint senior authors. DEAR EDITOR, Health-related quality of life (HRQOL) measure- References ments are important patient-reported outcomes when evaluating treatment responses and the effect of interventions in patients 1 Rotshild V, Hirsh-Raccah B, Miskin I et al. Comparing the clinical efficacy of COVID-19 vaccines: a systematic review and network with hand eczema (HE). In recent years, the disease-specific meta-analysis. Sci Rep 2021; 11:22777. Quality of Life in Hand Eczema Questionnaire (QOLHEQ) has 2 Ritchie H, Mathieu E, Rodes-Guirao L et al. Coronavirus (COVID- been increasingly used and validated in different languages.1–3 19) vaccinations. Available at: https://ourworldindata.org/covid- However, a Danish validation is missing. Thus, our objective vaccinations (last accessed 6 April 2022). was to assess the validity of single scores and the internal con- 3 MacDonald NE. Vaccine hesitancy: definition, scope and determi- sistency of the Danish version of the QOLHEQ. nants. Vaccine 2015; 33:4161–4. We translated the English version of the QOLHEQ into Dan- 4 Freeman D, Loe BS, Chadwick A et al. COVID-19 vaccine hesitancy in the UK: the Oxford coronavirus explanations, attitudes, and nar- ish by forward and backward translations in accordance with ratives survey (Oceans) II. Psychol Med 2020; 11:1–15. previously published guidelines.4 The QOLHEQ comprises 30 5 Salisbury D, Ramsay M, Noakes K. COVID-19 – SARS-CoV-2. In: items grouped in four domains: symptoms, emotions, func- Immunisations Against Infectious Disease (Green Book). London: Department tioning, and treatment and prevention. The total score has a of Health, 2021; Chapter 14a. range from 0 to 127, with higher scores indicating higher 6 Sotiriou E, Bakirtzi K, Papadimitriou I et al. COVID-19 vaccination impairment in HRQOL. In this cross-sectional study, patients intention among patients with psoriasis compared with immuno- with HE were recruited from the dermatological outpatient suppressed patients with other skin diseases and factors influencing their decision. Br J Dermatol 2021; 185:209–10. clinic at Bispebjerg Hospital between March and December 7 Mahil SK, Yates M, Langan SM et al. Risk-mitigating behaviours in 2018, and between August and December 2019. They were people with inflammatory skin and joint disease during the COVID- asked to complete the QOLHEQ and reference instruments. 19 pandemic differ by treatment type: a cross-sectional patient sur- The reference instruments were the EuroQol 5 Dimensions 3 vey. Br J Dermatol 2021; 185:80–90. Levels (EQ-5D-3L), which is a generic HRQOL questionnaire 8 Bhutani T, Wong JW, Bebo BF et al. Access to health care in patients with five domains (mobility, self-care, usual activities, pain/ with psoriasis and psoriatic arthritis: data from National Psoriasis discomfort, anxiety/depression) and EQ-VAS, which is a visual Foundation survey panels. JAMA Dermatol 2013; 149:717–21. analogue scale (VAS) for self-rated health ranging from 0 to 100, with 100 indicating ‘best imaginable health state’. In Funding sources: (Appendix S2) and conflicts of interest state- addition to the patient-administered questionnaires, a trained ments (Appendix S3) can be found in the Supporting Information. physician assessed the patients’ HE severity with the Physician British Journal of Dermatology (2022) 187, pp246–273 Ó 2022 British Association of Dermatologists.