Association of outdoor activity restriction and income loss with patient-reported outcomes of psoriasis during the COVID-19 pandemic: A web-based survey.

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 health care and medicine. Some underwent income loss or unemployment, which placed them at additional risks of adverse health outcomes. 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 February 25, 2020, and March 6, 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. Secondary outcomes included perceived stress (visual analog scale), symptoms of anxiety (2-item Generalized Anxiety Disorder) and depression (2-item Patient Health Questionnaire), adherence to treatment, and health care use. Covariates included sex, 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 the supplemental materials (available via Mendeley at http://doi.org/10.17632/gtmhpx4g2f.1). The data were analyzed with R, version 3.5.2 (R Core Team, Vienna, Austria). Multivariable logistic regression was used to estimate the associations with adjustments. The effect size is presented as adjusted odds ratio (aOR) and 95% confidence interval (CI). P values of less than .05 were 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 the supplemental materials. 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 I ). Similarly, income loss was associated with the exacerbation of psoriasis, stress, and symptoms of anxiety and depression (Table II ). Differently, income loss was significantly associated with nonadherence to treatment but was not associated with health care utilization. To further determine the independent factors, stepwise regression was 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.

Table I

Associations of outdoor activity restriction with patient-reported outcomes of psoriasis

Patient-reported outcomes	Unaffected (n = 512)		Restricted (n = 291)				Quarantined at home or in hospital (n = 123)
	n (%)	OR	n (%)	OR (95% CI)	aOR (95%CI)∗	P	n (%)	OR (95% CI)	aOR (95%CI)∗	P
Deteriorated psoriasis	194 (37.9)	1	139 (47.8)	1.50 (1.12-2.01)	1.39 (1.03-1.88)	.034	72 (58.5)	2.31 (1.55-3.46)	2.08 (1.38- 3.15)	.001
Perceived stress (VAS, ≥7)	76 (14.8)	1	64 (22.0)	1.62 (1.12-2.34)	1.48 (1.01-2.18)	.044	30 (24.4)	1.85 (1.15-2.99)	1.51 (0.92-2.71)	.107
Anxiety (GAD-2, ≥3)	321 (62.7)	1	199 (68.4)	1.29 (0.95-1.75)	1.16 (0.85-1.60)	.346	94 (76.4)	1.93 (1.23-3.04)	1.66 (1.04-2.64)	.033
Depression (PHQ-2, ≥3)	327 (63.9)	1	209 (71.8)	1.44 (1.06-1.97)	1.23 (0.89-1.71)	.219	95 (77.2)	1.92 (1.21-3.04)	1.60 (1.00-2.59)	.053
Nonadherence to treatment	344 (67.2)	1	204 (70.1)	1.15 (0.84-1.56)	1.04 (0.76-1.45)	.793	86 (69.9)	1.14 (0.74-1.74)	1.06 (0.68-1.65)	.804
No health care use	339 (66.2)	1	198 (68.0)	1.09 (0.80-1.48)	1.09 (0.80-1.50)	.580	68 (55.3)	0.63 (0.42-0.94)	0.66 (0.44-1.00)	.049

aOR, Adjusted odds ratio; CI, confidence interval; GAD-2, 2-item Generalized Anxiety Disorder; OR, unadjusted odds ratio; PHQ-2, 2-item Patient Health Questionnaire; VAS, visual analog scale.

Adjusted for age, educational level, annual income, marital status, history of hypertension, type of psoriasis, and income loss.

Table II

Associations of income loss with patient-reported outcomes of psoriasis

Patient-reported outcomes	Unaffected (n = 263)		Reduced (n = 265)				Complete loss (n = 398)
	n (%)	OR	n (%)	OR (95% CI)	aOR (95% CI)∗	P	n (%)	OR (95% CI)	aOR (95% CI)∗	P
Deteriorated psoriasis	89 (33.8)	1	100 (37.7)	1.19 (0.83-1.69)	1.12 (0.77-1.62)	.561	216 (54.3)	2.32 (1.68-3.20)	2.15 (1.46-3.15)	<.001
Perceived stress (VAS, ≥7)	26 (9.9)	1	39 (14.7)	1.57 (0.93-2.67)	1.57 (0.91-2.71)	.103	105 (26.4)	3.27 (2.06-5.19)	3.26 (1.91-5.57)	<.001
Anxiety (GAD-2, ≥3)	146 (55.5)	1	174 (65.7)	1.53 (1.08-2.18)	1.39 (0.96-2.00)	.080	294 (73.9)	2.27 (1.63-3.15)	1.73 (1.17-2.56)	.006
Depression (PHQ-2, ≥3)	146 (55.5)	1	177 (66.8)	1.61 (1.13-2.29)	1.48 (1.02-2.15)	.038	308 (77.4)	2.74 (1.96-3.85)	2.37 (1.58-3.57)	<.001
Nonadherence to treatment	156 (59.3)	1	173 (65.3)	1.29 (0.91-1.84)	1.22 (0.84-1.76)	.292	305 (76.6)	2.25 (1.60-3.16)	2.18 (1.45-3.26)	<.001
No health care use	181 (68.8)	1	179 (67.5)	0.94 (0.65-1.36)	0.92 (0.62-1.35)	.656	245 (65.3)	0.73 (0.52-1.01)	0.78 (0.52-1.16)	.216

aOR, Adjusted odds ratio; CI, confidence interval; GAD-2, 2-item Generalized Anxiety Disorder; OR, unadjusted odds ratio; PHQ-2, 2-item Patient Health Questionnaire; VAS, visual analog scale.

Adjusted for age, educational level, annual income, marital status, history of hypertension, type of psoriasis, and outdoor activity restriction.

Loss of income and work-related benefits experienced by the unemployed consequently lead to impaired health outcomes through mechanisms involving unhealthy coping behaviors and increased psychological distress. 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 services further limited patients' abilities to access to health care, especially for those who were not familiar with or able to access teledermatology, resulting in discontinued treatment and deteriorated condition. In conclusion, telemedicine and a supply of medications in addition to mental health intervention are needed for patients with psoriasis to improve their health outcomes.