Adverse childhood experiences in patients with psoriasis

Abstract Introduction Adverse childhood experiences (ACEs) have been linked to occurrence of autoimmune diseases in adults, including psoriasis. Objectives To study the prevalence of ACEs in psoriasis patients, comparing them with a sample from the general population. Methods Three hundred and eighteen individuals were included (104 psoriasis patients and 214 controls). Patients and controls answered questions on an ACE study questionnaire about experiences of childhood abuse, negligence, domestic violence, and household dysfunction. Questionnaire scores range from zero (best result) to 8 (worst scenario). Psoriasis patients’ charts were reviewed for epidemiological, clinical, and treatment data. A Psoriasis Area Severity Index (PASI) was calculated from measurements taken when the questionnaire was administered. Results Psoriasis patients reported a median of 4 ACEs (interquartile range [IQR] = 3-5) while controls had a median of 3 (IQR = 2-4) with p < 0.0001. The number of ACEs was not associated with PASI, age of disease onset, or presence of associated arthritis (all p > 0.5). Female psoriasis patients had more ACEs than males (p = 0.04). Conclusion Patients with psoriasis have more ACEs than controls and ACEs were more common in female patients.


Introduction
Psoriasis is a chronic skin disorder that affects 1.5-2% of the general population in industrialized countries 1 and expresses itself clinically as well-defined, red plaques covered by silver scales. 2 Emotional, environmental, and autoimmune events have been associated with its occurrence. [2][3][4] Psoriasis patients may suffer from several psychological problems such as anxiety, depression, alexithymia, poor self-esteem, and suicidal ideation. 1,3 Currently, psoriasis is considered to be a psycho-dermatological illness, i.e. a physical disease that can be caused or intensified by psychological events. 3 Supporting this hypothesis, psychosocial factors have been identified in 40-80% of psoriasis onset or flares. 5 Experiencing traumatic events and psychological suffering that exceed the individual's capacity to cope may be interrelated to onset, worsening, and/ or reoccurrence of several autoimmune disorders. 3 It is hypothesized that the increasing prevalence of autoimmune diseases during recent decades in industrialized countries should be at least partially attributed to high stress levels. 6 During stress response, rising levels of catecholamines and glucocorticoids affect the function of several immune cells and modify the profile of cytokines released. 7 Childhood traumatic experiences have been connected to the appearance of several autoimmune disorders 3 and to increased inflammatory markers such as C reactive protein levels into adulthood. 8 Simonic´ et al., 3 studied 100 psoriasis patients, finding that they had higher prevalence of negative traumatic experiences during developmental periods than controls.
The influence of these events can be affected by social, cultural, and individual patient characteristics.
Some studies reported high prevalence of adverse childhood events (ACEs) in regions with low income. 9,10 Herein we studied ACEs in a sample of Brazilian patients with psoriasis to determine their frequency and associations with clinical variables.

Methods
All procedures performed in this study were Patients and controls answered a questionnaire on epidemiological data (that covered age, sex, income, years of formal study, and religion) and answered the ACEs Study Questionnaire. This instrument encompasses questions on childhood traumatic events and covers eight domains: emotional abuse, physical abuse, violent treatment by mother, use of substances/ alcohol at home, sexual abuse, mental disease at home, jailed family member and parental divorce. 11 The questionnaire score ranges from zero (best result) to 8 (worst scenario). The questionnaire used comprises questions selected by Soares et al. 12 from those on an ACE questionnaire 11

translated and validated in Brazilian
Portuguese by Grassi-Oliveira et al. 13 Psoriasis patients had their charts reviewed for disease duration, psoriasis subset, involvement of nails and scalp, and presence of arthritis. The extent of skin disease was evaluated using the Psoriasis Area Severity Index (PASI), 14  The significance level adopted was 5%.      systemic drugs for treatment was also non-significant (p = 0.61).

Study of psoriasis variables with ACEs
A comparison of the number ACEs in patients with disease onset at < 30 years of age with those whose onset was at ≥ 30 years of age returned p = 0.44. The immune active state. 16 CRH receptors are increased in psoriasis compared to normal skin, and expression of CRH-R1 (CRH receptor type 1) is correlated with PASI. 18 We could not prove any links between number of ACEs and age of disease onset, severity of skin disease measured by PASI, or presence of associated arthritis.
Moreover, patients requiring systemic treatment, which can be considered as a marker for more severe disease, had similar number of ACEs to those not on systemic treatment. Other investigators have studied the association between extent of skin disease and psychological disturbance and also failed to prove any association. 3,15 Psoriasis is as frequent in males as in females in several countries, including in Brazil, 19 but the female subset of our psoriasis sample had higher numbers of ACEs than the male subset. In Brazil, adolescent females have more adverse experiences than males and the most common ACE was parental separation, followed by emotional neglect, and domestic violence. 20 The most common current ACEs in both psoriasis and control samples were emotional abuse and use of substance/alcohol at home.
Children who have suffered ACEs have a tendency to become dysfunctional adults and this may influence their parenting practices; they may reproduce the problem in the next generation. 21 It is therefore important to identify them in order to intervene in this vicious cycle.
The knowledge that psoriasis patients may be at risk of having higher numbers of ACEs offers the attending physician an opportunity to identify this situation and to refer these patients to receive adequate support to interrupt perpetuation of the cycle.
The present study has several limitations. The low number of participants and their low PASI are some of these. Another is the study design that relies on the patients' memory to recall ACEs. However, the study has the merit of revealing the possible association between psoriasis and ACEs.

Disclosure
No conflicts of interest declared concerning the publication of this article.