Psoriasis is a chronic, relapsing, immune-mediated inflammatory skin disorder characterized by hyperproliferation of keratinocytes, vascular changes, and infiltration of inflammatory cells, particularly T-lymphocytes and dendritic cells. ^[1] Globally, it affects approximately 2–3% of the population, although the prevalence varies considerably across regions depending on genetic, environmental, and lifestyle-related factors. In India, epidemiological data reveal a prevalence range between 0.44% and 2.8%, with variations across rural and urban populations, ethnic subgroups, and climatic zones. ^[2] Plaque-type psoriasis (psoriasis vulgaris) is the most frequently encountered clinical variant, accounting for approximately 80–90% of cases, followed by guttate, pustular, erythrodermic, and inverse psoriasis. ^[3]

Although psoriasis has historically been viewed and managed as a dermatological condition with cutaneous manifestations such as erythematous plaques, silvery scaling, and pruritus, contemporary evidence supports its classification as a systemic inflammatory disease. The pathophysiology involves dysregulated cytokine signalling, particularly within the IL-23/IL-17 axis, which not only mediates epidermal hyperplasia but also underpins associations with metabolic syndrome, psoriatic arthritis, cardiovascular disease, and other systemic comorbidities. ^[4] Thus, psoriasis should be viewed through a multisystem lens that considers both its dermatological and extra-cutaneous impact.

Importantly, the psychosocial and psychiatric burden of psoriasis is increasingly recognized as a critical domain of patient suffering and health-related quality of life (HRQoL). Unlike many other chronic disorders, psoriasis is conspicuous in its visual presentation. Lesions on the face, hands, scalp, or other visible areas often provoke stigma, avoidance, and discrimination in social and professional environments. This results in a profound erosion of self-esteem, body image, and interpersonal confidence. ^[5] Patients may experience anticipatory anxiety regarding public scrutiny or rejection, which contributes to patterns of social withdrawal, emotional distress, and, in severe cases, psychiatric morbidity.

Studies from diverse populations have demonstrated that the psychological impact of psoriasis may equal or exceed that of life-threatening diseases such as cancer, myocardial infarction, or diabetes mellitus. ^[6] In particular, anxiety and depression are common among psoriasis patients, with reported prevalence rates ranging from 30% to 60% depending on population, setting, and assessment methods. ^[7] A meta-analysis by Dowlatshahi et al. found that patients with psoriasis were 1.5 times more likely to experience depression and twice as likely to have suicidal ideation compared to the general population . ^[8] Notably, these psychological comorbidities are often underdiagnosed due to lack of routine screening and are rarely integrated into routine dermatological practice, especially in low- and middle-income countries.

The relationship between psoriasis severity and psychological morbidity is bidirectional. While higher disease severity is associated with worse emotional outcomes, psychological distress may also exacerbate disease activity via neuroimmunological pathways involving the hypothalamic-pituitary-adrenal axis and pro-inflammatory cytokines such as TNF-α and IL-6. ^[9] This complex interplay underscores the need for holistic care approaches that recognize the mind-skin connection in chronic dermatologic conditions. Moreover, factors such as disease chronicity, poor treatment response, relapsing-remitting nature, and treatment fatigue further compound the psychological burden over time. ^[10]

India, with its unique sociocultural landscape, presents additional challenges in managing psoriasis and its psychological implications. Cultural norms around appearance, family expectations, religious practices (such as restrictions in temple entry), and marriage prospects are heavily influenced by perceptions of physical purity and aesthetics. Stigmatization is often more pronounced in women, who face both internalized and external pressures related to appearance and perceived worth. ^[11] Additionally, low mental health literacy, limited access to psychiatric services, and social taboos around psychological illness contribute to poor detection and management of psychiatric comorbidities in dermatology clinics. ^[12]

The Dermatology Life Quality Index (DLQI), developed by Finlay and Khan, is one of the most widely used patient-reported outcome measures for assessing the effect of dermatological conditions on daily life. It encompasses dimensions such as symptoms, embarrassment, personal relationships, work, and treatment-related challenges. ^[13] The Hospital Anxiety and Depression Scale (HADS) is another validated instrument designed to identify anxiety and depression symptoms in non-psychiatric hospital settings. Its psychometric properties make it suitable for dermatology patients who may experience somatic symptoms that could confound other screening tools. ^[14] These tools, in combination, provide valuable insights into both functional impairment and psychological distress among patients with psoriasis.

Several Indian studies have attempted to examine the psychological aspects of psoriasis. However, most have focused either solely on quality of life or on psychiatric morbidity, with limited integration of both domains. Furthermore, very few have systematically analyzed the influence of disease severity (measured by PASI), body site involvement, socioeconomic factors, and demographic characteristics on quality of life and mental health. Tertiary care centers, especially teaching hospitals, often cater to a diverse patient population from both urban and rural backgrounds, thereby offering a unique opportunity to capture a more representative clinical and psychosocial profile.

Despite the growing recognition of psychological comorbidities in psoriasis, a comprehensive understanding of the psychosocial burden in Indian clinical settings remains inadequate. There is a compelling need to systematically assess the interplay between clinical severity, visible disfigurement, demographic vulnerabilities, and mental health outcomes in patients with psoriasis. Identifying such patterns will inform integrative therapeutic strategies, promote early psychiatric referrals, and guide policy-level interventions for mental health screening in dermatology clinics.

Furthermore, with the advent of biologic therapies and patient-centered care models, it is imperative to incorporate patient-reported outcomes such as DLQI and HADS into routine clinical assessments. These tools not only help quantify the subjective disease burden but also support shared decision-making and therapeutic prioritization in resource-constrained settings.

This study was therefore designed with the primary objective of assessing the quality of life and psychological morbidity among psoriasis patients attending a tertiary care hospital. The secondary objectives included identifying key clinical and sociodemographic predictors associated with worse quality of life and psychological distress. By bridging this evidence gap, we aim to promote holistic, culturally sensitive, and clinically actionable care models for psoriasis management in low- and middle-income contexts.

This study employed a hospital-based, cross-sectional observational design conducted in the dermatology outpatient department of a tertiary care teaching hospital in Hamdard Institute of Medical Sciences & Research. The study was carried out over a 12-month period from January 1, 2024, to December 31, 2024. All procedures were carried out in accordance with the Declaration of Helsinki. Participants were briefed about the study objectives, confidentiality assurances, and their right to withdraw, and informed written consent was obtained in their preferred languages.

Participant Selection

Participants were enrolled through consecutive sampling from among adult patients attending the dermatology outpatient clinic. Inclusion criteria comprised adults aged 18 years and above with a clinical diagnosis of psoriasis based on typical lesion morphology and distribution. Patients were excluded if they had a prior clinical diagnosis of psychiatric illness preceding the diagnosis of psoriasis, were currently using psychotropic medications, or had systemic comorbidities known to independently affect quality of life, such as malignancy, end-stage renal disease, decompensated liver disease, or advanced heart failure. Patients who were unable to complete the questionnaire due to language barriers, cognitive impairments, or low literacy levels, despite assistance, were also excluded.

Sample Size Determination

Sample size was calculated using the single population proportion formula with the assumption that 50% of psoriasis patients experience psychological morbidity. Using a 95% confidence interval and a margin of error of 10%, the minimum required sample size was determined to be 96. To allow for better statistical power, multivariable regression analysis, and possible incomplete responses, 150 patients were finally recruited and included in the study.

Data Collection Procedures

Data collection was conducted in a single session during the patient’s outpatient visit. Each participant underwent clinical examination and was then interviewed by a trained research assistant in a confidential setting. Clinical data were recorded by the attending dermatologist who was blinded to questionnaire responses to minimize observer bias. Patients were assisted as needed to ensure complete and accurate responses. Standardized instructions were provided for all instruments, and culturally validated translated versions were used for patients not fluent in English.

Assessment of Quality of Life

Quality of life was assessed using the DLQI,^[13] a validated 10-item instrument that evaluates dermatology-specific quality of life over the preceding week. The DLQI captures patient perceptions across domains including symptoms and feelings, daily activities, leisure, work or school, personal relationships, and treatment-related burdens. Each item is scored from 0 (not at all) to 3 (very much), yielding a total score ranging from 0 to 30. Higher scores indicate greater impairment in quality of life. Scores are interpreted as follows: 0–1 (no effect), 2–5 (small effect), 6–10 (moderate effect), 11–20 (very large effect), and 21–30 (extremely large effect).

Assessment of Psychological Morbidity

Psychological morbidity was measured using the Hospital Anxiety and Depression Scale (HADS)^[14], which includes 14 items—seven for anxiety (HADS-A) and seven for depression (HADS-D). Each item is scored from 0 to 3, resulting in subscale scores ranging from 0 to 21. A score of 8 or above on either subscale indicates clinically significant anxiety or depression. The HADS is widely validated for hospital-based populations and was chosen because it minimizes confounding by excluding somatic symptoms common to chronic medical conditions.

Clinical Assessment of Psoriasis Severity

Disease severity was quantified using the Psoriasis Area and Severity Index (PASI)^[15], which assesses erythema, induration, and scaling along with the extent of body surface area involvement across four anatomical regions—head, upper limbs, trunk, and lower limbs. PASI scores range from 0 to 72, with higher scores reflecting greater disease severity. PASI scoring was performed by the treating dermatologist during clinical examination prior to the administration of psychological and QoL questionnaires.

Collection of Sociodemographic and Clinical Variables

In addition to the clinical and psychometric tools, a structured questionnaire was administered to capture sociodemographic and disease-related variables. These included age, sex, marital status, education level, monthly household income, occupational status, duration of illness since diagnosis, site of lesion involvement (especially visible areas such as the face, hands, and scalp), and history of previous systemic or topical treatments.

Data Quality Assurance

To ensure data accuracy, all instruments were pre-tested in a pilot group of 15 psoriasis patients (not included in the final study sample) to assess clarity and cultural relevance. Regular cross-checks and random audits were conducted by the principal investigator to ensure completeness and consistency of data entries. Double data entry was employed for electronic database creation to minimize typographical errors.

Statistical Analysis

Data were entered and analyzed using IBM SPSS Statistics version 26.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics were used to summarize the characteristics of the study population. Continuous variables were reported as means and standard deviations or medians and interquartile ranges, depending on data distribution, while categorical variables were presented as frequencies and percentages. To examine the relationship between disease severity (PASI scores), psychological morbidity (HADS scores), and quality of life (DLQI scores), Pearson’s correlation coefficient was calculated for continuous variables. Group differences in mean DLQI and HADS scores across sociodemographic variables were assessed using independent sample t-tests and one-way ANOVA, as appropriate. Multivariate linear regression models were constructed to identify independent predictors of impaired quality of life (DLQI) and elevated psychological morbidity (total HADS score). Variables entered into the regression model included age, gender, educational attainment, income level, PASI score, duration of psoriasis, and presence of lesions on visible body areas. Model fit was assessed using adjusted R-squared values, and multicollinearity diagnostics were performed to evaluate the independence of predictors. Statistical significance was set at a p-value of less than 0.05 for all analyses.

Participant Characteristics

A total of 150 psoriasis patients were included in the final analysis. The mean age of the study participants was 38.5 years (±12.3), and males accounted for a majority of the cohort (58%). The median duration of illness was 4.2 years, with an interquartile range (IQR) of 1.5 to 9.5 years, reflecting the chronic nature of the disease. Most patients (76%) had plaque-type psoriasis, the most common clinical subtype. A considerable proportion of participants (48%) belonged to the lower-income group, while 42% had not completed education beyond the high school level. Involvement of visible sites such as the face, hands, or scalp was reported in 63% of patients. The mean Psoriasis Area and Severity Index (PASI) score was 12.8 (±5.6), indicating a moderate level of disease severity in the sample.

Quality of Life Assessment

Assessment using the DLQI revealed a mean score of 13.2 (±6.4), signifying a substantial impact on patients' daily functioning and emotional well-being. When categorized, 12 patients (8%) reported a mild effect on life quality (DLQI <5), 39 patients (26%) experienced a moderate effect (DLQI 5–10), 69 patients (46%) reported a very large impact (DLQI 11–20), and 30 patients (20%) had extremely high impairment (DLQI ≥21). (Figure 1) These findings highlight that more than two-thirds of patients experienced a DLQI score above 10, indicating serious quality-of-life limitations attributable to psoriasis.

Figure 1: Quality of Life among Psoriasis Patients

Psychological Morbidity

HADS was used to assess emotional distress. Clinically significant anxiety symptoms (HADS-A ≥8) were found in 58.7% of participants, while 46.7% had depressive symptoms (HADS-D ≥8). Patients who screened positive for both anxiety and depression had significantly higher DLQI scores compared to those without such symptoms (p<0.001), indicating a close association between psychological burden and impaired quality of life. (Table 2)

Correlation Analysis

Pearson correlation analysis demonstrated a strong positive correlation between PASI and DLQI scores (r = 0.52, p < 0.001), confirming that clinical severity directly affects quality of life. PASI scores also showed moderate correlations with HADS-A (r = 0.43, p = 0.002) and HADS-D (r = 0.41, p = 0.004), suggesting that increasing disease severity is associated with heightened psychological distress. Additionally, DLQI scores correlated strongly with both anxiety (r = 0.58, p < 0.001) and depression scores (r = 0.54, p < 0.001), reinforcing the interdependent nature of dermatological and psychological morbidity.

Regression Analysis

Multivariate linear regression was used to determine predictors of poor quality of life and psychological morbidity. The model for DLQI (dependent variable) showed that PASI score (β = 0.34, p < 0.001), involvement of visible body sites (β = 0.27, p = 0.004), low-income status (β = 0.22, p = 0.008), and longer disease duration (β = 0.19, p = 0.012) were significant predictors of quality of life impairment. (Tabl2 3) These findings suggest that both clinical and socioeconomic factors contribute to QoL burden.

In a separate regression model assessing psychological morbidity (defined as total HADS score >15), higher DLQI scores emerged as the strongest predictor (β = 0.41, p < 0.001). Female gender (β = 0.28, p = 0.002) and low educational attainment (β = 0.23, p = 0.009) were also significantly associated with increased psychological distress. (Table 4) These findings emphasize the multifactorial nature of psychological distress in psoriasis, driven by disease severity, reduced quality of life, gender disparities, and educational disadvantage.

This cross-sectional study provides a comprehensive evaluation of the quality of life and psychological morbidity among psoriasis patients in a tertiary care hospital . The results underscore the profound impact of psoriasis beyond its dermatological manifestations, highlighting the disease’s entwinement with psychological distress and social disadvantage. A mean DLQI score of 13.2 in our cohort signifies a very large impact on patients’ day-to-day functioning, while the high prevalence of clinically significant anxiety (58.7%) and depression (46.7%) further emphasizes the biopsychosocial burden of this chronic inflammatory condition. These findings are in strong concordance with previous literature from both high-income and low- to middle-income countries.

Psoriasis, particularly when persistent and severe, has been consistently shown to impair multiple domains of health-related quality of life (HRQoL), including physical discomfort, social stigma, limitations in daily activities, and interference with personal and professional roles. The mean DLQI score observed in our study (13.2 ± 6.4) is comparable to global data. A large study by Kotewicz M et al. reported mean DLQI scores ranging from 10 to 14 in psoriasis cohorts, demonstrating significant disruption in patient wellbeing. ^[16] Indian studies have reported similar findings. Arora et al., in a study of 198 psoriasis patients in North India, reported a mean DLQI of 12.5, with nearly 60% of patients experiencing a very large or extremely large effect on life quality. ^[17]

Our DLQI distribution data further confirm that over two-thirds of patients in our cohort reported moderate to extremely large impact (DLQI >10), reflecting both the physical and psychological dimensions of disease burden. Notably, visible lesion involvement (face, scalp, hands) was independently associated with higher DLQI scores. Similar findings were reported by Jankowiak et al., who emphasized that patients with lesions in socially conspicuous locations experience disproportionately higher psychological and social distress due to stigmatization and perceived judgment from peers and the public. ^[18]

The positive correlation observed between PASI scores and DLQI (r = 0.52, p < 0.001) supports the notion that greater clinical severity is associated with more profound quality-of-life impairment. This association has been well documented in the literature. In a study by Maul et al., PASI was consistently linked to HRQoL outcomes, although the strength of correlation varied across populations, indicating the potential influence of cultural and psychosocial modifiers. ^[19] Moreover, our regression analysis confirmed that PASI, along with longer disease duration and visible lesion involvement, significantly predicted higher DLQI scores.

Psychological morbidity was also significantly associated with PASI in our study. Moderate positive correlations were observed between PASI and both anxiety (HADS-A: r = 0.43, p = 0.002) and depression (HADS-D: r = 0.41, p = 0.004) scores. These findings echo those of Khawaja et al., who  found increased risk of depression and anxiety among patients with moderate-to-severe psoriasis compared to controls. ^[20] Although causal relationships cannot be inferred from cross-sectional data, the chronicity, visibility, and often unpredictable course of psoriasis likely create a fertile ground for psychological distress, especially in the absence of structured psychosocial support.

The high prevalence of anxiety (58.7%) and depression (46.7%) observed in our sample is concerning and consistent with global estimates. A meta-analysis by Dowlatshahi et al. reported pooled prevalence rates of depression and anxiety among psoriasis patients as 28% and 20%, respectively, although rates were higher in clinical samples than in population-based surveys. ^[8] Studies from India have reported variable prevalence depending on tools used, but most show a consistent trend of underrecognized psychological morbidity. ^{[2, 21]}

Our findings confirm that psychological morbidity is not merely a secondary consequence of disease severity. In multivariate analysis, factors such as female gender and lower educational attainment also independently predicted elevated HADS scores, highlighting the intersecting role of gender, education, and health literacy. Women may experience greater emotional burden due to sociocultural emphasis on physical appearance, marital expectations, and caregiving roles. ^[22] Lower education likely impedes access to coping resources, delays health-seeking behavior, and amplifies vulnerability to chronic stressors.

Moreover, the strong correlation between DLQI and psychological morbidity (DLQI vs HADS-A: r = 0.58; DLQI vs HADS-D: r = 0.54) reinforces the need to address emotional well-being as an integral component of psoriasis care. Psoriasis-related stigma, frustration with recurrent flares, and adverse effects of long-term pharmacotherapy all contribute to reduced self-esteem, hopelessness, and social isolation, forming a vicious cycle that perpetuates both skin and psychological symptoms.^[9]

Our study highlights the crucial role of social determinants—particularly income and education—in shaping the lived experience of psoriasis. Low-income status was a significant predictor of both DLQI and psychological morbidity, underscoring financial constraints as a barrier to adequate treatment, nutrition, and mental health care. Several studies have previously demonstrated that individuals from lower socioeconomic backgrounds often face delayed diagnosis, treatment interruptions, and reduced access to biologics, all of which contribute to poorer outcomes.^{[23, 24]} Education not only facilitates access to healthcare information but also empowers individuals to adopt proactive coping strategies and navigate complex treatment pathways.^[25]

The chronic nature of psoriasis also intersects with occupational disadvantage. Many patients report absenteeism, reduced productivity, and job discrimination, especially those in public-facing or manual labor roles. ^[26] These socio-occupational consequences amplify emotional burden and contribute to long-term psychological morbidity, highlighting the need for workplace accommodations and policy-level interventions. Our findings support international recommendations advocating for integrated psychosocial care in dermatology. The International Psoriasis Council and World Health Organization both emphasize the need for routine mental health screening in psoriasis management. ^[27,28] Yet, such integration is rarely practiced in resource-constrained settings, partly due to lack of training among dermatologists and limited availability of mental health professionals.

Dermatology clinics should incorporate brief, validated screening tools as part of initial and follow-up evaluations. Additionally, referrals to psychologists or psychiatrists should be streamlined for patients exhibiting moderate-to-severe psychological distress. Patient education, support groups, and psychodermatology consultations can further facilitate coping and reduce stigma. Treatment goals should extend beyond PASI improvement to include psychosocial well-being and quality of life enhancement.

The strengths of this study include its relatively large sample size, use of culturally validated psychometric tools (DLQI, HADS), and comprehensive statistical analysis correlating disease severity, demographic variables, and psychosocial outcomes. Unlike many earlier studies, we systematically analyzed predictors of both quality of life and psychological morbidity. However, some limitations must be acknowledged. First, the cross-sectional design precludes inference of causal relationships between variables. Second, being a single-center study, the findings may not be generalizable to all regions or healthcare settings in India. Third, unmeasured factors such as treatment adherence, support systems, personality traits, or previous psychiatric history could have influenced the observed outcomes. Despite these limitations, the study provides compelling evidence of the psychosocial complexity of psoriasis in a representative Indian cohort.

This study reaffirms that psoriasis is more than a skin disease—it is a chronic systemic condition with deep psychological and social ramifications. Disease severity, visible disfigurement, gender disparities, and socioeconomic disadvantage collectively shape patient experiences, leading to marked quality-of-life impairment and high prevalence of anxiety and depression. Routine screening for psychological distress, holistic patient-centered care, and targeted interventions for vulnerable subgroups are essential to improve health outcomes. Future research should focus on longitudinal assessments and interventional studies evaluating the impact of integrated psychodermatologic care in diverse Indian populations.

Source of Support: Nil

Conflict of Interest: None Declared

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