Cumulative Life Damage

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Dermatology Reports 2011; volume 3:e5 Cumulative life damage in dermatology Kristina Ibler, Gregor B.E. Jemec Department of Dermatology, Roskilde Hospital; Health Sciences Faculty, University of Copenhagen, Denmark been applied in studies of degenerative disease, but the perspective offered may also provide important insights into e.g. adolescent disease where major life events shape the responsiveness of the patients to patophysiological changes. Correspondence: Gregor B.E. Jemec, Department
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  [page 8][Dermatology Reports 2011; 3:e5] Cumulative life damagein dermatology Kristina Ibler, Gregor B.E. JemecDepartment of Dermatology, RoskildeHospital; Health Sciences Faculty,University of Copenhagen, Denmark  Abstract Cumulative life damage is an old concept of considerable face validity, which has attractedmore scientific interest in the fields of sociol-ogy and psychology than in medicine over the years. The research examines the intercon-nectivity of the many factors which shape thedevelopment of individuals or institutions over time. By focussing on time, context andprocess, life course research highlights the dif-ferent effects seemingly similar events may have at different points in time and in differ-ent contexts. Introduction Cumulative life damage is an old concept of considerable face validity, which has attractedmore scientific interest in the fields of sociol-ogy and psychology than in medicine over the years. In a philosophical context the concept of determinism has been the subject of much dis-cussion. In sociology the analysis of factors which convey either advantages or disadvan-tages to the development of an individual over the entire course of their life have been tradi-tional area of interest. In an empirical rather than a theoretical context it is of obvious inter-est how general conditions, resources and sin-gle events in the course of a lifetime add up toshape the entire life course. Life course can bedefined as a  sequence of socially defined events and roles that the individual enacts over time 1 and the research examines the interconnectiv-ity of the many factors which shape the devel-opment of individuals or institutions over time. By focussing on time, context andprocess, life course research highlights the dif-ferent effects seemingly similar events may have at different points in time and in differ-ent contexts. In a health context, this may beparticularly appropriate in chronic diseases where the morbidity is influenced by severalfactors over long periods of time. Here lifecourse research is looking at how related neg-ative health events, assembled into a specificdiagnosis but spread over a lifetime, summateunder the influence of the persons abilitiesand resources to produce an overall impact of the disease. Life course research has thereforebeen applied in studies of degenerative dis-ease, but the perspective offered may also pro- vide important insights into e.g. adolescentdisease where major life events shape theresponsiveness of the patients to patophysio-logical changes. Cumulative life course impair-ment in dermatology In medicine it may be directly linked to theconcepts proposed by the World HealthOrganisation in the definition of health. Threecore concepts are used to describe morbidity:Impairment, disability and handicap.Impairment is defined as the loss or abnormal-ity of physical bodily structure or function, of logic-psychic srcin, or physiological or anatomical srcin. The impairment is the basicpathology of the disease, e.g. the eczema, thescleroderma or the tumour. Impairments leadto disabilities. Disability is defined as any lim-itation or function loss deriving from impair-ment that prevents the performance of anactivity in the time-lapse considered normalfor a human being. The disability in a derma-tological context is therefore e.g. the psychoso-cial consequences to the individual with asevere acne vulgaris. The disability may inturn lead to a handicap, which is defined as thedisadvantaged condition deriving from impair-ment or disability limiting a person performinga role considered normal in respect of their age, sex and social and cultural factors. A der-matological example of handicap would be theloss of employment suffered in consequence of hand eczema.In many ways the concept of cumulative lifecourse impairment (CLCI) is particularly suit-ed to dermatology, as the diseases are rarely lethal and well within the realm of the psy-chosocial sphere due to their immediate visi-bility and obvious presence even to theuntrained eye. Stigma as well as socialisationare therefore important factors when assess-ing the impact of skin disease on patients. Inaddition to these psychosocial consequencesof skin disease, dermatological conditions fre-quently have symptoms that are difficult tocontrol adequately influencing the resourcesof the patients negatively. The balancebetween the stressors and coping abilities of the patients may therefore be more volatile, which over the course of longstanding diseasemay lead to more negative events and lifecourse changing consequences. It may beargued that CLCI reflects the handicap of thedisease in the broadest sense of the word, butoffers the dynamic perspectives of time andcontext thereby identifying additional opportu-nities for adjuvant interventions beyond thenarrow biological process at the root of thehandicap. In the following we will review someof the evidence supporting the concept of CLCIin dermatology. Hand eczema Hand eczema is a major occupational hazardin many countries, and management often dif-ficult. It has an acknowledged negative impacton the quality of life, 2-5 but studies also suggestthat the development of hand eczema causesCLCI. In a one year follow-up study of second-ary individual prevention in health care work-ers with occupational hand eczema by Diepgenand co-workers, a beneficial effect of the inter- vention was found, but in spite the structuredintervention 9% of the patients studied had lefttheir job due to the skin disease. 6 This sug-gests that even with specific interventionsaimed at improving the coping abilities of thepatients, occupational hand eczema has a sig-nificant life course impact. A similar result was found in a study of kitchen employees. 7 The relevance of CLCI in occupational handeczema is underlined by the findings in a study by Cvetkovski  et al  . that indicating the conse-quences of the disease are affected by the lifeconditions of the patients. Patients with lower socioeconomic status were found to have ahigher risk of prolonged sick leave, job change,and loss of job, whereas the identification of aspecific contact allergy was not found to be arisk factor for poor prognosis. 8 Severe handeczema and lower socioeconomic status wereboth associated with a lower quality of life. 2 Ina study by Fowler   et al. it was found that handeczema had a detrimental effect on workingproductivity, activity impairment and healthcare costs. 3 Acne  Acne is a common skin disease, and inmilder forms often seen as physiological. In Dermatology Reports 2011; volume 3:e5 Correspondence: Gregor B.E. Jemec, Departmentof Dermatology, Roskilde Hospital; HealthSciences Faculty, University of Copenhagen,Denmark.Tel. +45.47322603 - Fax: +45.47322699.E-mail: gbj@regionsjaelland.dk Key words: handicap, cumulative life impairment,morbidity, quality of life, skin disease.Received for publication: 30 March 2011. Accepted for publication: 30 March 2011.This work is licensed under a Creative Commons Attribution 3.0 License (by-nc 3.0). ©Copyright K. Ibler and G.B.E. Jemec, 2011 Licensee PAGEPress, Italy Dermatology Reports 2011; 3:e5  doi:10.4081/dr.2011.e5   [Dermatology Reports 2011; 3:e5][page 9] terms of CLCI two factors have been describedin the literature: psychological consequencesand social consequences.This is a skin disease that affects predomi-nantly teenagers, i.e. persons at a dramaticdevelopmental stage of their life, making themsusceptible to many factors. It is well estab-lished that quality of life is adversely affectedby acne, and the consequences of this hasbeen the topic of some debate. Although stud-ies have found no increase in depressionamong acne patients, 9 a recent populationbased study found acne associated withdepression, suggesting insufficient coping inthis group of patients. 10 It has previously beenshown that acne is a common diagnosisamong dermatological patients who commitsuicide due to their disease, indicating thatacne may be associated with the ultimateCLCI. 11 In societal terms data exist to suggest thatacne can have a considerable negative CLCI, asunemployment has been shown to be higher among acne patients than controls, suggestingthat the changed appearance and possible pre- judice associated with skin disease negatively affects the prospects of acne patients. Theseobservations may however also be secondary tothe self-image of acne patients or due to other hitherto undescribed mechanisms. Atopic eczema  Atopic eczema (AE) is a frequent diseaseaffecting up to 1 in 5 preschool children, andalthough the majority of cases appear toresolve spontaneously, a history of AE conveysa lifelong increase in the risk of developinghand eczema. Because of the frequent sponta-neous resolution AE is more difficult to study in a CLCI context. It has never the less beenshown that patients with severe AE in child-hood have delayed socialization, indicatingthat the skin disease has psychosocial conse-quences which reach beyond signs and symp-toms of the disease itself. Several studies havedescribed the negative effects on the quality of life of the individual patient, and recently thishas been extended to the household. 12,13 By describing the family impact of skin disease,Finlay and coworkers have suggested that thefamily unit as a whole is adversely affected by skin disease, indicating that CLCI may occur indirectly as a consequence of illness in thefamily.For adult AE patients it has however beenshown that AE leads to job changes andincreased number of sick days off work. Theflares as well as the increased risk of flaresassociated with jobs that involve a chemical or mechanical strain on the skin play a role in thecareer choice of AE patients, thereby providinglong-term influence on their life course.Finally AE may lead to job loss, and if severe todisability pension. 14  Although the numbers aresmall it is also suggested that a number of patients receive permanent disability pensionsdue to AE indicating major CLCI. Psoriasis Psoriasis is often taken as a prototypicalskin disease causing embarrassment and stig-ma. It is also suggested that it may be triggeredby significant life events, suggesting that it isat least temporarily linked to major traumaticlife events. 15 It has furthermore been suggest-ed that while most diseases may be associateddepression at their onset, psoriasis, myocar-dial infarction, and migraine are also associat-ed with with depression on subsequent flares,suggesting that the disease may have a moreprofound effect on the psyche than many other diseases. 16  Whether any subsequent psychoso-cial impact of psoriasis on the lives of patientsis a consequence of this psychological mecha-nism or due to stigma is not currently known,but it has been shown that psoriasis is associ-ated with low quality of life particularly amongthe socioeconomically challenged. 17 The rela-tionship between the psychosocial burden of psoriasis, the disease severity and the socialand economical achievements of psoriasispatients is at best described as complex. 18 It ishowever clear that the diagnosis of psoriasis,and in particular severe psoriasis, is associat-ed with concrete life-event differences fromother patients. 19 For psoriasis patients approx-imately 30 years old, higher divorce rates areseen than in others, suggesting the diseaseaffects social connectivity, which may alsoreflect in the worklife of patients. 20 This is fur-ther supported by the observation that psoria-sis is the second most common disease associ-ated with disability pensions. 21 Psoriasis hastherefore been suggested as a model of derma-tological life impairment. 22 Conclusions The concept of CLCI appears well suited todescribe the handicap of dermatological dis-ease. The chronic recurrent nature of the dis-eases, coupled with their visibility and theability of lay persons to recognise pathology immediately, indicates that skin disease may affect both context and process repeatedly leading to handicap. Data are however sorely lacking to provide an adequate model of CLCIin dermatological disease. The present know -ledge is based on few descriptive surveys, mostoften without a control group making it diffi-cult to draw conclusions. Furthermore, datahave not been gathered systematically, whichmeans that a number of possible confounderssuch as education, socioeconomic status, fam-ily context etc. are not available. The introduc-tion of CLCI into dermatological researchtherefore necessitates the development of appropriate technologies to identify the mech-anisms that would allow predictions to bemade and in consequence possible interven-tion studies.In addition to methodological developmentssuch as prospective databases, additional case-control studies are needed to further describethe available data and substantiate the role of CLCI in dermatology. References 1.Giele JZ, Elder GH Jr. (). Methods of LifeCourse Research: Qualitative andQuantitative Approaches. Thousand OaksCA: Sage 1998 p.22.2.Cvetkovski RS, Zachariae R, Jensen H, etal. Quality of life and depression in a pop-ulation of occupational hand eczemapatients. Contact Dermatitis 2006;54:106-11.3.Fowler JF, Ghosh A, Sung J, et al. Impact of chronic hand dermatitis on quality of life, work productivity, activity impairment,and medical costs. J Am Acad Dermatol2006;54:448-57.4.Agner T, Andersen KE, Brandao FM, et al.Hand eczema severity and quality of life: across-sectional, multicentre study of handeczema patients. Contact Dermatitis2008;59:43-7.5.Skoet R, Zachariae R, Agner T. Contactdermatitis and quality of life: a structuredreview of the literature. Br J Dermatol2003;149:452-6.6.Apfelbacher CJ, Soder S, Diepgen TL, Weisshaar E.The impact of measures for secondary individual prevention of work-related skin diseases in health care work-ers: 1-year follow-up study. ContactDermatitis 2009;60:144-9.7.Soder S, Diepgen TL, Radulescu M, et al.Occupational skin diseases in cleaningand kitchen employees: course and quality of life after measures of secondary individ-ual prevention. J Dtsch Dermatol Ges2007;5:670-6.8.Cvetkovski RS, Zachariae R, Jensen H, etal. Prognosis of occupational handeczema: a follow-up study. Arch Dermatol2006;142:305-11.9.Rehn LM, Meririnne E, Höök-Nikanne J, etal. Depressive symptoms, suicidal ideationand acne: a study of male Finnish con-scripts. J Eur Acad Dermatol Venereol2008;22:561-7.10.Halvorsen JA, Stern RS, Dalgard F, et al.Suicidal ideation, mental health problems,and social impairment are increased inadolescents with acne: a population-basedstudy. J Invest Dermatol 2011;131:363-70. Review  [page 10][Dermatology Reports 2011; 3:e5] 11.Purvis D, Robinson E, Merry S, Watson P. Acne, anxiety, depression and suicide inteenagers: a cross-sectional survey of New Zealand secondary school students. JPaediatr Child Health 2006;42:793-6.12.Kemp AS. Cost of illness of atopic dermati-tis in children: a societal perspective.Pharmacoeconomics 2003;21:105-13.13.Kemp AS. Atopic eczema: its social andfinancial costs. J Paediatr Child Health1999;35:229-31.14.Holm EA, Esmann S, Jemec GB. The hand-icap caused by atopic dermatitis--sick leave and job avoidance. J Eur AcadDermatol Venereol 2006;20:255-9.15.Arslanagi ć N, Arslanagi ć R. Effect of psy-chological trauma caused by war on mani-festations of psoriasis. Med Arh 2003;57:145-7.16.Gili M, Garcia-Toro M, Vives M, et al.Medical comorbidity in recurrent versusfirst-episode depressive patients. ActaPsychiatr Scand 2011;123:220-7.17.O'Neill P, Kelly P. Postal questionnairestudy of disability in the community asso-ciated with psoriasis. BMJ 1996;313:919-21.18.Kimball AB, Jacobson C, Weiss S, et al. Thepsychosocial burden of psoriasis. Am JClin Dermatol 2005;6:383-92.19.Seidler EM, Kimball AB. Socioeconomicdisability in psoriasis. Br J Dermatol2009;161:1410-2.20.Frangoes JE, Kimball AB. Divorce/mar-riage ratio in patients with psoriasis com-pared to patients with other chronic med-ical conditions. J Invest Dermatol 2008;128:s87.21.Menné T, Bachmann E. Permanent disabil-ity from skin diseases. A study of 564patients registered over a six year peri-od. Derm Beruf Umwelt 1979;27:37-42.22.Kimball AB, Gieler U, Linder D, et al.Psoriasis: is the impairment to a patient'slife cumulative? J Eur Acad Dermatol Venereol 2010;24:989-1004. Review
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