Evaluation of fatigue and its correlation with quality of life index, anxiety symptoms, depression and activity of disease in patients with psoriatic arthritis

Abstract

Background
Psoriatic arthritis is associated with psychosocial morbidity and decrease in quality of life. Psychiatric comorbidity also plays an important role in the impairment of quality of life and onset of fatigue.

Objectives
This study aimed to assess the prevalence of fatigue in psoriatic arthritis patients and to correlate it to quality of life indexes, functional capacity, anxiety, depression and disease activity.

Patients and methods
This cross-sectional study was performed on outpatients with psoriatic arthritis. Functional Assessment of Chronic Illness Therapy – Fatigue (FACIT-F; version 4) was used to measure fatigue; 36-Item Short Form Health Survey (SF-36) and Psoriasis Disability Index (PDI) to measure quality of life; Health Assessment Questionnaire (HAQ) to assess functional capacity; Hospital Anxiety and Depression (HAD) scale to measure anxiety and depression symptoms; Psoriasis Area and Severity Index (PASI), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and Clinical Disease Activity Index (CDAI) to evaluate clinical activity.

Results
In all, 101 patients with mean age of 50.77 years were included. The mean PDI score was 8.01; PASI score, 9.88; BASDAI score, 3.59; HAQ score, 0.85; HAD – Anxiety (HAD A) score, 7.39; HAD Depression (HAD D) score, 5.93; FACIT–Fatigue Scale (FACIT-FS) score, 38.3 and CDAI score, 2.65. FACIT-FS was statistically associated with PASI (rs −0.345, p<0.001), PDI (rs −0.299, p<0.002), HAQ (rs −0.460, p<0.001), HAD A (rs −0.306, p=0.002) and HAD D (rs −0.339, p<0.001). The correlations with CDAI and BASDAI were not confirmed. There was statistically significant correlation with all of the domains of SF-36 and FACIT-F (version 4).

Conclusion
Prevalence of fatigue was moderate to intense in <25% of patients with psoriatic arthritis. Fatigue seems to be more related to the emotional and social aspects of the disease than to joint inflammatory aspects, confirming that the disease’s visibility is the most disturbing aspect for the patient and that “skin pain” is more intense than the joint pain.

Full text

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Clinical, Cosmetic and Investigational Dermatology 2017:10 155–163
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ORIGINAL RESEARCH
open access to scientific and medical research
Open Access Full Text Article
http://dx.doi.org/10.2147/CCID.S124886
Evaluation of fatigue and its correlation with
quality of life index, anxiety symptoms, depression
and activity of disease in patients with psoriatic
arthritis
Claudio Carneiro1,2
Mario Chaves2
Gustavo Verardino2
Ana Paula Frade3
Pedro Guimaraes
Coscarelli4
Washington Alves Bianchi5,6
Marcia Ramos-e-Silva3
Sueli Carneiro2,3
1Health Ministry, 2Sector of
Dermatology, School of Medical
Sciences and University Hospital,
State University of Rio de Janeiro,
3Sector of Dermatology, University
Hospital and School of Medicine,
Federal University of Rio de Janeiro,
4General Medicine Department,
University Hospital and School of
Medical Sciences, State University
of Rio de Janeiro, 5Sector of
Rheumatology, Santa Casa da
Misericórdia, 6University Hospital
and School of Medical Sciences, State
University of Rio de Janeiro, Rio de
Janeiro, Brazil
Background: Psoriatic arthritis is associated with psychosocial morbidity and decrease in
quality of life. Psychiatric comorbidity also plays an important role in the impairment of qual-
ity of life and onset of fatigue.
Objectives: This study aimed to assess the prevalence of fatigue in psoriatic arthritis patients
and to correlate it to quality of life indexes, functional capacity, anxiety, depression and disease
activity.
Patients and methods: This cross-sectional study was performed on outpatients with psoriatic
arthritis. Functional Assessment of Chronic Illness Therapy – Fatigue (FACIT-F; version 4) was
used to measure fatigue; 36-Item Short Form Health Survey (SF-36) and Psoriasis Disability
Index (PDI) to measure quality of life; Health Assessment Questionnaire (HAQ) to assess
functional capacity; Hospital Anxiety and Depression (HAD) scale to measure anxiety and
depression symptoms; Psoriasis Area and Severity Index (PASI), Bath Ankylosing Spondylitis
Disease Activity Index (BASDAI) and Clinical Disease Activity Index (CDAI) to evaluate
clinical activity.
Results: In all, 101 patients with mean age of 50.77 years were included. The mean PDI score
was 8.01; PASI score, 9.88; BASDAI score, 3.59; HAQ score, 0.85; HAD – Anxiety (HAD A)
score, 7.39; HAD Depression (HAD D) score, 5.93; FACIT–Fatigue Scale (FACIT-FS) score,
38.3 and CDAI score, 2.65. FACIT-FS was statistically associated with PASI (rs –0.345, p<0.001),
PDI (rs –0.299, p<0.002), HAQ (rs –0.460, p<0.001), HAD A (rs –0.306, p=0.002) and HAD D
(rs –0.339, p<0.001). The correlations with CDAI and BASDAI were not confirmed. There was
statistically significant correlation with all of the domains of SF-36 and FACIT-F (version 4).
Conclusion: Prevalence of fatigue was moderate to intense in <25% of patients with psoriatic
arthritis. Fatigue seems to be more related to the emotional and social aspects of the disease
than to joint inflammatory aspects, confirming that the disease’s visibility is the most disturbing
aspect for the patient and that “skin pain” is more intense than the joint pain.
Keywords: psoriasis, arthritis, fatigue, quality of life, anxiety, depression, questionnaires
Introduction
Psoriasis (Ps) is a chronic inflammatory disease with worldwide distribution affecting
both sexes in the proportion of 1 man:1.3 women, at any age, but more frequently in
the 3rd and 4th decades of life. The predisposition seems to be genetically determined
and familial occurrence is present in ~30% of cases.1
Psoriatic arthritis (PA) has characteristic features of joint inflammation, with
edema, erythema and heat in one or more joints; Moreover, 6%–40% of patients
Correspondence: Marcia Ramos-e-Silva
Sector of Dermatology, University
Hospital and School of Medicine, Federal
University of Rio de Janeiro, Rua Dona
Mariana 143/C-32, Rio de Janeiro 22280-
020, Brazil
Email ramos.e.silva@dermato.med.br
Journal name: Clinical, Cosmetic and Investigational Dermatology
Article Designation: ORIGINAL RESEARCH
Year: 2017
Volume: 10
Running head verso: Carneiro et al
Running head recto: Evaluation of fatigue in patients with psoriatic arthritis
DOI: http://dx.doi.org/10.2147/CCID.S124886
This article was published in the following Dove Press journal:
Clinical, Cosmetic and Investigational Dermatology
8 May 2017
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Carneiro et al
with Ps have arthritis.2–7 The age for the beginning of PA is
~40 years, and patients with severe forms may have earlier
manifestation.8
Fatigue is a frequent complaint in patients with arthritis,
which they correlate to tiredness.9,10 In humans, fatigue is
more central than peripheral, as well as being more psy-
chological than physiological and thus is very difficult to
quantify.11,12 It is the result of biochemical and physiologi-
cal changes and is manifested by weakness, weariness and
behavioral disturbances with reduced work capacity or
lack of resistance and a subjective feeling of tiredness and
discomfort.12–16 There is no detection of actual muscle weak-
ness in most people who complain of fatigue. The fatigued
individual cannot handle complex problems and tends to be
less reasonable in everyday life and to exhibit inferiority
complex, anxiety and depression.12,15,17,18
Multiple factors accelerate the onset of fatigue, including
heat, humidity and altitude, while others, such as pleasure,
rhythm, motivation, knowledge of the stages of the task to
be performed and fitness, delay it. Sex and age also influence
the onset of fatigue.12,17
Almost all chronic diseases may evolve with fatigue. The
differential diagnosis includes infections; anemia; neoplastic,
connective tissue, endocrine, neurological, chronic kidney,
chronic liver, metabolic and ionic diseases; sleep and psy-
chiatric alterations; and many others.19–22
Quality-of-life (QoL) health status refers to “dimen-
sions” that are specific and directly related to health condi-
tions, excluding environmental factors, income, beliefs and
freedom.23–26
The global well-being of patients and their cohabitants,
who experience impairment in QoL of patients and higher
levels of anxiety and depression, is markedly worsened by
Ps.27 Tezel et al28 studied 80 patients with PA, 40 patients with
Ps and 40 healthy subjects in terms of QoL and functional
status and found that patients with Ps and PA had worse
QoL and patients with PA had worse functional status than
healthy individuals.
The severity of Ps is usually assessed only relative to
the extent of the skin or joint involvement, leaving aside the
assessment of fatigue, QoL and symptoms of anxiety and
depression. However, Ps may provoke a negative impact as
large as that of debilitating and life-threatening disorders.
Such effects include stress, embarrassment, stigma and physi-
cal discomfort. Over time, there is an increasing emotional
involvement of the patient to the detriment of his/her social
life, decreased productivity at school or work and lower self-
esteem. Patients believe that fatigue is linked to the disease
activity, poor sleep, stress of joint components and lack of
sense of well-being, and they consider it more important than
the joint symptoms.29,30
The objectives of this investigation were to verify the
prevalence of fatigue in patients with PA undergoing treat-
ment at the outpatient clinics of 2 university hospitals in Rio
de Janeiro, through the Functional Assessment of Chronic
Illness Therapy – Fatigue (FACIT-F) tool; to assess the disease
activity, QoL, functional capacity and symptoms of depres-
sion and anxiety in these patients and, finally, to correlate
fatigue with the QoL index, functional capacity, symptoms
anxiety and depression, as well as disease activity.
Patients and methods
This was a cross-sectional observational clinical–epide-
miological study.31 The research project was approved by
the ethical committees of both hospitals: Clementino Fraga
Filho University Hospital (Federal University of Rio de
Janeiro – UFRJ) and Pedro Ernesto University Hospital (State
University of Rio de Janeiro – UERJ).
Patients
Patients of both sexes (n=101), aged ≥18 years, with clini-
cal diagnoses based on the 2006 Classification Criteria for
Psoriatic Arthritis (CASPAR)32 were examined. All patients
provided signed informed consent. They were from the
Sector of Dermatology (Cutaneous–Articular Diseases Out-
Patient Clinic) of the Clementino Fraga Filho University
Hospital (Federal University of Rio de Janeiro) and Sector
of Rheumatology (Spondiloarthritis Out-Patient Clinic) of
the Pedro Ernesto University Hospital (State University of
Rio de Janeiro). Exclusion criteria were diabetes, liver or
kidney failure, hypothyroidism or untreated adrenal insuf-
ficiency, neurological diseases from constant muscle activity,
myopathy, anemia (hematocrit <30%) and chronic infections,
as well as use of medications such as diuretics, beta-blockers,
methyldopa and barbiturates. Hospitalized or home-in-bed
patients were also excluded.
Methods
Patients who fulfilled the CASPAR were interviewed, and
they answered the questionnaires, for which permission for
use was obtained from the authors by email. After a brief
explanation by one of the health care team members, the
following protocols were filled out: 36-Item Short Form
Health Survey (SF-36),33 Psoriasis Disability Index (PDI),30
Hospital Anxiety and Depression (HAD) scale,34 FACIT-F,
FACIT–Fatigue Scale (FACIT-FS)35 and Health Assessment

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Evaluation of fatigue in patients with psoriatic arthritis
Questionnaire (HAQ).36 Disease activity was measured with
Psoriasis Area and Severity Index (PASI),37 Bath Ankylosing
Spondylitis Disease Activity Index (BASDAI)38 and Clinical
Disease Activity Index (CDAI).39
Statistical evaluation
The 2 × 2 tables were analyzed with Fisher’s exact test. In
the remaining contingency tables, the χ2 test was used. In the
correlation analysis, the Pearson correlation coefficient r was
used. The level of statistical significance was set at 0.05. All
analyses were performed with the R software, version 2.11,
free and open source code.
Results
Population studied
Three hundred patients with Ps from the Sector of Derma-
tology of the Clementino Fraga Filho University Hospital,
UFRJ (Cutaneous–Articular Diseases Out-Patient Clinic)
and 150 patients with spondyloarthritis from the Sector
of Rheumatology of the Pedro Ernesto Hospital, UERJ
(Spondyloarthritis Out-Patient Clinic) were evaluated, and
of them, 101 fulfilled the inclusion criteria, with the follow-
ing characteristics:
Sex: 57 men (56.4%) and 44 women (43.6%)
Color: 61 Caucasian, 33 mixed and 7 black
Average age: 50.77 years (sd =0.48); minimum: 23 years;
maximum: 79 years
Articular disease
The articular disease was clinically and/or radiologically
diagnosed and showed the distribution presented in Table 1.
QoL, fatigue, functional capacity and
disease activity
The SF-36 tool with 8 domains is presented in Table 2. All
domains (FC, functional capacity; PAL, physical aspects
limitation; GHS, general health status; SA, social aspects;
EA, emotional aspects; VIT, vitality) ranged from 0 to 100,
except PAIN, whose minimum value was 10, and mental
health (MH), whose minimum value was 24.
The intermediary values show that all SF-36 domains
were impaired by the disease.
There are 4 domains of FACIT-F, as seen in Table 3 (PW,
physical well-being; S/F W, social and family well-being;
EW, emotional well-being; FunW, functional well-being and
a Fatigue Scale). There are specific scores that add some
domains, such as TOI (PW + FunW + Fatigue Scale), G (PW
+ S/F W + EW + FunW) and F (PW + S/F W + EW + FunW
+ Fatigue Scale).
The FACIT-F domains showed alterations, as did the
SF-36 that measures the same variables. The sum of scores
(TOI, F and G) also showed alterations.
Fatigue was intense to moderate in the 1st quartile (25
patients), as seen in Figure 1.
FACIT Scale, PASI, PDI, BASDAI, HAQ, HAD A, HAD
D and CDAI scores showed minimum and maximum values
as distributed in Table 4, which shows the variation of the
scores found for fatigue, disease activity, QoL, functional
capacity as well as the symptoms of anxiety and depression.
The correlation was strong between the FACIT-FS and
the skin disease activity rates, as assessed by PASI; QoL
assessed by PDI; and anxiety and depression assessed by
HAD. However, the correlations with the peripheral and axial
joint disease activity indexes, as assessed by the BASDAI
and the CDAI, were not confirmed. Figures 2 and 3 illustrate
these findings.
Table 1 Distribution of articular involvement
Articular involvement Women/men White Mixed Black
Peripheral 26/22 25 21 2
Axial 1/13 10 3 1
Both 17/22 26 9 4
Table 2 Distribution of SF-36 components
SF-36 domains Median Mean
FC 60 59.52
PAL 50 51.04
PAIN 42 52.59
GHS 62 59.81
SA 62.50 63.72
MH 68 65.71
EA 97 66.77
VIT 60 58.5
Note: PAIN indicates the pain domain of SF-36.
Abbreviations: SF-36, 36-Item Short Form Health Survey; FC, functional capacity;
PAL, physical aspects limitation; GHS, general health status; SA, social aspects; MH,
mental health; EA, emotional aspects; VIT, vitality.
Table 3 Distribution of FACIT-F (version 4) components
Domain Minimum Maximum Median Mean
PW 1 28 21.00 27.00
S/F W 3 28 20.00 20.71
EW 3 24 17.00 16.82
FunW 0 28 18.27 18.00
TOI 2 107 74.00 75.70
G 25 107 73.30 76.18
F 25 159 113.5 113.59
Notes: TOI, PW + FunW + FACIT F; G, PW + S/F W + EW + FunW; F, PW + S/F
W + EW + FunW + FACIT F.
Abbreviations: FACIT-F, Functional Assessment of Chronic Illness Therapy –
Fatigue; PW, physical well-being; S/F W, social and family well-being; EW, emotional
well-being; FunW, functional well-being.

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Carneiro et al
The correlation was strong between FACIT-F and the
different domains of SF-36 that included not only physical
and functional aspects but also emotional, social and mental
health, ranging below 0.001.
Fatigue Scale scores were correlated with FACIT-F
domains, which included not only physical and functional
aspects, but also those that assessed emotional and social
aspects. There were no correlations with TOI and F score
sums because both contain the FACIT Scale.
Discussion
Ps has a high worldwide prevalence and a broad spectrum
of cutaneous and articular manifestations, with a negative
impact on the QoL, function, indexes of anxiety and depres-
sion as well as increased sensation of fatigue, especially in
the presence of associated arthritis, and may be associated
with decreased survival.40
Lomholt41 suggested that the earlier the disease starts in a
population, the more the environmental factors involved in its
onset are relevant. The low PASI, PDI and fatigue scores in
our patients can be credited to the sunny climate of the city
of Rio de Janeiro and the daily habits of wearing less clothing
and more sun exposure of its inhabitants, and the fact that
Rio de Janeiro is one of the happiest cities in the world.42,43
There are no specific indicators to assess the disease
activity in PA, or they are still in the process of validation.
The tools deployed nowadays for assessing the disease have
been insufficiently validated or are borrowed from rheuma-
toid arthritis (RA). We decided to use the CDAI, unlike other
indexes used in RA, which does not include any measure in
response to the acute phase response (APR) in its formula.
In cases of PA, the erythrocyte sedimentation rate (ESR)
and C-reactive protein (CRP) do not assume high values and
often bear no relation with the intensity of the inflammation.
The CDAI designed for RA may therefore be used in PA and
other arthritis models.39
At the Group for Research and Assessment of Psoriasis
and Psoriatic Arthritis (GRAPPA) meetings,44 the possibility
of using an already existing measure to evaluate PA or the
need to create a new one specific to the disease was discussed
FACIT-FS
03
0
1st
quartile
2nd
quartile
3rd
quartile
4th
quartile
42 47 52
01020304
05
0
25
20
15
10
5
0
Number of patients
Figure 1 Distribution of FACIT-FS scores.
Abbreviation: FACIT-FS, Functional Assessment of Chronic Illness Therapy–Fatigue Scale.
Table 4 Distribution of FACIT-FS, PASI, PDI, BASDAI, HAQ,
HAD A/D and CDAI domain values
Instrument Minimum Maximum Median Mean
FACIT-FS 0 52 42 38.3
PASI 0 39.9 8 9.88
PDI 0 35 5 8.01
BASDAI 0 9.25 3.2 3.59
HAQ 0 2.90 0.88 0.85
HAD A 0 21 7 7.39
HAD D 0 20 6 5.93
CDAI 2 58 24 24.65
Abbreviations: FACIT-FS, Functional Assessment of Chronic Illness Therapy–
Fatigue Scale; PASI, Psoriasis Area and Severity Index; PDI, Psoriasis Disability
Index; BASDAI, Bath Ankylosing Spondylitis Disease Activity Index; HAQ, Health
Assessment Questionnaire; HAD A/D, Hospital Anxiety and Depression scale –
Anxiety/Depression; CDAI, Clinical Disease Activity Index.

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Evaluation of fatigue in patients with psoriatic arthritis
several times and their advantages and disadvantages were
analyzed.45
Gupta and Gupta 46 reported that Ps has a greater impact
on the QoL of patients aged between 18 and 45 years, and that
men suffer a higher degree of work-related stress due to the
disease. These authors did not find any differences between
sexes in terms of the disease’s severity.
Sampogna et al,47 in their assessment of hospitalized
patients, found that women aged >65 years had a greater
reduction in QoL related to Ps. In this study, only patients with
arthritis aged >18 years were included, and the PASI average
was 9.88 and the PDI average was 8.01, showing that even in
this population, the majority of patients showed an impairment
that can be considered mild to moderate, corroborating the
influence of environmental factors, which was also observed
by one of the authors (unpublished data).48
Most studies consider stress a factor significantly related
to the worsening of the disease. Each population has specific
psychological characteristics. Thus, the manner in which
coastal city-dwelling Brazilians deal with stress and how it
influences the disease is a relevant topic in the study of Ps.
Various types of questionnaires have been developed
in an attempt to assess patients’ QoL, including questions
about physical and mental health, as well as aspects related
to their family, friends and social life. These questionnaires
can be generic or specific to dermatology diseases and these
provide scientific and systematic grounds to measure what
matters to the patient.49
FACIT-FS
0
0
20
40
60
10 20
PASI
30 40
FACIT-FS
05 15 25 35
0
20
40
60
10 20
PDI
30
FACIT-FS
0246 810
0
20
40
60
BASDAI
AB
CD
FACIT-FS
0
0
20
40
60
10 20
CDAI
30 40 50
60
Figure 2 Correlation between FACIT-FS scores and (A) PASI, (B) PDI, (C) BASDAI and (D) CDAI scales.
Note: Scatter plots and adjustment curves of 95% CI (condence interval) are shown.
Abbreviations: FACIT-FS, Functional Assessment of Chronic Illness Therapy– Fatigue Scale; PASI, Psoriasis Area and Severity Index; PDI, Psoriasis Disability Index; BASDAI,
Bath Ankylosing Spondylitis Disease Activity Index; CDAI, Clinical Disease Activity Index.
60
ABC
HAQ
1.00.0
0
10
20
FACIT- FS
FACIT- FS
FACIT- FS
30
40
50
2.0 3.0
60
HAD A
1005
0
10
20
30
40
50
60
0
10
20
30
40
50
15 20 25
HAD D
1005 15 20
25
Figure 3 Correlation between FACIT-FS scores and (A) HAQ, (B) HAD A and (C) HAD D scales.
Note: Scatter plots and adjustment curves of 95% CI (condence interval) are shown.
Abbreviations: FACIT-FS, Functional Assessment of Chronic Illness Therapy – Fatigue Scale; HAQ, Health Assessment Questionnaire; HAD A/D, Hospital Anxiety and
Depression scale – Anxiety/Depression.

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The variation between the QoL questionnaires is often
related to the degree to which they emphasize objective
dimensions compared to subjective ones, the extent to which
the various areas are covered and the format of questions
rather than differences in the definition of QoL.49,50
For this study, the PDI was chosen for including some
detailed domains, such as personal relationships, leisure and
daily activities, whether at school, at work or in general.
Moreover, Japiassu, in 2008,48 noted that PDI and Dermatol-
ogy Life Quality Index (DLQI), widely used for all derma-
toses, are reliable and equivalent to evaluate the QoL of Ps
patients with or without arthritis.
Studies on fatigue in RA have shown that patients con-
sider their fatigue frustrating and exhausting and that it is
much more related to pain intensity, depressed mood and
nonrestorative sleep than to the inflammation itself and
anemia.9,51–53 For many patients, fatigue is not a disorder,
but something expected and normal in their daily routine.54,55
Pollard et al51 concluded that disease activity does not
play any role in the level of fatigue and the relation between
inflammation and fatigue is not as strong as generally
assumed. Psychosocial factors may be important in the
perpetuation of fatigue, and some of them may make certain
patients more prone to fatigue.
Treharne et al55 stated that psychological factors and
depression are major contributors to fatigue, but not the only
ones. The pain, the disease activity and the painful joint count
were moderately associated, while swollen joints, anemia,
ESR and PCR were not. Skin diseases are known to have
deleterious effects on the QoL of patients and Ps, considered
by many as a psychodermatosis amid its multicausality,
presents the psychosocial factor to a relevant extent. Indeed,
social and psychological factors are codeterminants of the
health–disease process, in a biopsychosocial model, wherein
diseases are the result of several factors. The contribution
of psychosocial factors varies from disease to disease, from
person to person and between worsening episodes in the
same person.
It has already been shown that the patients’ vision of Ps
is not associated with the severity of the case, suggesting
that they respond psychologically more to their own view
than to the actual severity of the disease. It explains why it
is sometimes not possible to associate the impact of Ps with
the severity of the condition, or why this ratio is weak.56
When the domains of QoL are stratified, the most affected
in Ps are personal relationships and daily activities, reflecting
the stigmatizing burden in patients’ everyday life, particularly
in relationships. It is therefore important to evaluate the Ps
patient’s perception regarding their health, disability and
their QoL, as well as how this perception is associated with
the perception of pain and fatigue.
The negative impact of Ps on different QoL domains is
comparable to, or even greater than that of, other potentially
fatal chronic diseases.57 Patients with severe Ps associated
with diabetes, asthma or bronchitis would rather have the
underlying disease than the skin disease.25 Many patients,
when comparing the involvement of the joint with that of
the skin, literally say that the skin bothers them much more
than the pain, inflammation and joint deformity.
Studies in patients with Ps show that 3 out of 4 patients
avoid sporting or swimming activities because of the disease,
one-third of them are inhibited in their sexual relationships
and the disease influences career choices in 25%.58,59
Hughes et al 60 were the first to demonstrate that derma-
tological patients, whether outpatients or hospitalized, have
higher prevalence of psychiatric disorders than the general
population. Since then, several studies have been published
reporting a prevalence ranging from 14% to 70%,61–64
although causal inferences cannot be made due to their
sectional designs. A prospective study with dermatologi-
cal patients without psychiatric morbidity at the first visit
showed an incidence of psychiatric disorders, after 1 month,
by 7.6%, with even higher percentages in patients with
unsatisfactory treatment results.65 The risk of developing a
psychiatric disorder was 3 times higher in patients who did
not get better with treatment.64 Magin et al66 demonstrated,
in a longitudinal study, evidence that stress and depression,
but not anxiety, may play a role in the multifactor etiology
of skin diseases. Longitudinal studies are therefore needed
to define the correct direction of this association.
Although studies conducted in Western populations have
shown that the prevalence of nonpsychotic mental disorders
ranges from 7% to 26%, with an average of 17% (12.5% in
men and 20% in women), studies show that, in Brazil, this
rate can be much higher, ranging from one-third to 50% of
patients.67 The average PDI value was 8.4, higher than the
value of 7.6 found by Japiassu.48 Such values correlated with
fatigue in a statistically significant way.
Although the association between the disease and the pres-
ence of symptoms of anxiety and depression was high in the
study due to its sectional design, it was not possible to estab-
lish the correct causal relationship between both of them and
fatigue, with which it was statistically significantly correlated.
Using PDI with HAD and fatigue represents an interesting
study strategy, because both deal with issues linked to emo-
tional aspects of the life of patients who have a skin disease.

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Evaluation of fatigue in patients with psoriatic arthritis
Minnock et al68 measured fatigue as a sensitive and
independent pattern in PA patients treated with anti-tumor
necrosis factor (TNF), using a numerical scale from 0 to 10.
Fatigue levels were 5.6 (2.3) and 3.6 (2.2) (p=0.001) at the
beginning and 3 months later, respectively, and it was found
that fatigue was an independent and sensitive measure to
assess changes in patients with PA, when compared with
HAQ, pain and CRP.
Gladman et al69 assessed the effects of 40 mg of subcu-
taneous adalimumab every 14 days in terms of functional
impairment, QoL, fatigue and pain in patients with PA com-
pared to placebo. The same questionnaires were used and they
concluded that the group treated with anti-TNF experienced
reductions in their functional limitations, fatigue and pain,
along with an improved QoL.
Fatigue was moderate to severe in a quarter of patients,
less prevalent than seen in RA,51–53 and correlated with the
disease activity and not the cutaneous articular disease,
confirming the findings that the visibility of the disease is
highly relevant to patients and that the “skin pain” and the
“soul pain” are much more intense than the pain and joint
inflammation.56
Conclusion
Fatigue was prevalent in patients with PA monitored in the
Cutaneous–Articular Diseases Out-Patient Clinic of HUCFF/
UFRJ and in the Spondyloarthritis Out-Patient Clinic of
HUPE/UERJ. It was intense to moderate in a quarter of
patients. The PASI, BASDAI and CDAI indexes were satisfac-
tory in the evaluation of disease activity and were consistent
with mild-to-moderate disease intensity in most patients. The
HAQ was able to assess patients’ functional capacity, showing
that the average inability ranged from mild to moderate, while
SF-36, PDI and FACIT-F were able to assess the QoL in its
many aspects, showing greater impairment in personal rela-
tionships, emotional aspects and daily activities. The fatigue
assessed by the FACIT-FS statistically significant correlated
the indexes of QoL and the symptoms of anxiety and depres-
sion with the disease activity assessed by PASI. There was no
correlation, however, with CDAI nor with BASDAI, which
measure the articular and axial disease activity. The “skin
pain” seems to be more intense than the joint pain.
Final considerations
The study of fatigue in PA is intriguing and leads to several
considerations: Is depression a cause or a consequence of
the disease and of its severity? Is there a distinct pattern of
response to stress in patients with Ps? How to assess it? What
is the real influence of environmental factors on fatigue? Is
the disease’s visibility the only factor valued by the patient?
What is the magnitude of the “skin pain”?
Acknowledgments
This work was supported by CNPq (National Council of
Scientific and Technological Development). The authors
hereby state that the current paper is based on the Master’s
thesis submitted by Dr Claudio Carneiro, who obtained the
title of Master of Sciences from the University of the State
of Rio de Janeiro with this thesis.
Disclosure
The authors report no conflicts of interest in this work.
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