Psoriasis and Fatigue

Fatigue is a common and often disabling symptom that occurs in patients with chronic inflammatory and autoimmune diseases, cancer, neurological diseases and a number of other conditions in which inflammation and/or cellular stress occurs. Fatigue may be defined as ‘an overwhelming sense of exhaustion, tiredness, languidness, languor, lassitude, and listlessness. It is a subjective feeling which is distinct from weakness, and has a gradual onset.  Fatigue can be Acute and/or Chronic (ongoing state of tiredness), that leads to mental or physical exhaustion, or both, and prevents people from functioning within normal boundaries.

There is emerging evidence that points to the innate immune system as an important ‘fatigue generator’, brought on by invading pathogens, autoimmune diseases, cancer or other ‘danger-signals’, as well as cellular stress responses. Many dermatological diseases and conditions demonstrate inflammatory or autoimmune features, suggesting that fatigue can be a common symptom in a number of chronic skin diseases. Also, psoriasis shares common pathways of immune signalling with other inflammatory diseases including psoriatic arthritis and rheumatoid arthritis (RA).1

The reduction of productivity and work capacity caused by fatigue has been studied by industrial psychologists. In these studies, the importance of physical or mental motivational factors has been clearly demonstrated. Real muscular weakness, however, cannot be detected in most individuals who complain about fatigue. The individual affected by fatigue is often unable to handle complex mental problems and tends to be less reasonable. Inferiority complexes may surface. In neurologic and psychiatric departments, anxiety and depression are frequently diagnosed in fatigued patients. 2

In one study stressed psoriasis patients, responding to a comprehensive series of questionnaires had the following physical and psychological symptoms: constant sensation of exhaustion (78.54%); memory problems (72.54%); constant fatigue (70.58%). In another study constant and excessive fatigue and the inability to work occurred in 56.86% (F) and 43.13% (M) of respondents. 3

In one clinical study researchers wanted to determine the relationship between fatigue and disease-related and psychosocial variables in psoriatic arthritis (PsA). They interviewed 499 patients attending the University of Toronto PsA Clinic using a modified fatigue severity scale (mFSS) questionnaire.  Results showed that moderate fatigue occurred in 49.5% of PsA patients and severe fatigue in 28.7%. 4

In another clinical study in plaque psoriasis patients, researchers found nearly 50% of psoriasis patients suffered from substantial fatigue. The fatigue severity was also associated with smoking, pain, and depression, but not with psoriasis severity. 5

Because fatigue is a perceived phenomenon, researchers and clinicians rely on subjective measures to indicate the patients’ level of fatigue and impact on their quality of life. It gives an overall picture of the patient and where they are at and plays a roll in determining the need for intervention or effectiveness of treatment. The 9-item Fatigue Severity Scale (FSS) is one of the most commonly used self-report questionnaires to measure fatigue. 6

The FSS questionnaire contains nine statements that attempt to explore severity of fatigue symptoms. Read each statement and circle a number from 1 to 7, depending on how appropriate they felt the statement applied to them over the preceding week. A low value indicates that the statement is not very appropriate whereas a high value indicates agreement (1 disagree to 7 agree).

FSS Questionnaire 7

During the past week, I have found that: Score
  1. My motivation is lower when I am fatigued.
1 2 3 4 5 6 7
  1. Exercise brings on my fatigue.
1 2 3 4 5 6 7
  1. I am easily fatigued.
1 2 3 4 5 6 7
  1. Fatigue interferes with my physical functioning.
1 2 3 4 5 6 7
  1. Fatigue causes frequent problems for me.
1 2 3 4 5 6 7
  1. My fatigue prevents sustained physical functioning.
1 2 3 4 5 6 7
  1. Fatigue interferes with carrying out certain duties and responsibilities
1 2 3 4 5 6 7
  1. Fatigue is among my three most disabling symptoms.
1 2 3 4 5 6 7
  1. Fatigue interferes with my work, family, or social life.
1 2 3 4 5 6 7

Circle closest to how you feel – (1 disagree, 7 agree).

FSS Scoring: Add up the circled numbers and divide by 9. ________

A Fatigue Severity Scale (FSS) score of 4 – defined as the patient is suffering from “Fatigue” and >?5.1 as suffering from “Severe Fatigue”.

Compare results with the following scores:

  • People who do not experience fatigue score about 2.8
  • People with Lupus score about 4.6
  • People with Lyme Disease score about 4.8
  • People with fatigue related to Multiple Sclerosis score about 5.1
  • People with Chronic Fatigue Syndrome score about 6.1

NOTE: The FSS might have difficulties distinguishing fatigue from depression (the influence of pain may influence scores on the FSS).

For those that have scored 5 or more it is seriously recommended that you see your practitioner and discuss the possibility as to whether you may also be suffering from depression.

References:

  • Skoie I.M. et al.; Fatigue in psoriasis: a phenomenon to be explored; British Journal of Dermatology (2015) 172, pp1196–1203
  • Carneiro C. et al.;  Fatigue in Psoriasis With Arthritis; SKINmed. 2011;9:34–37
  • Leovigildo E. S. et al.; Stress level of people with psoriasis at a public hospital; An Bras Dermatol. 2016;91(4):446-54.
  • Husted JA, Tom BD, Schentag CT, et al.; Occurrence and correlates of fatigue in psoriatic arthritis Annals of the Rheumatic Diseases 2009;68:1553-1558.
  • Skoie I.M. et al.; Fatigue in psoriasis – a controlled study; British Journal of Dermatology; 2017; DOI: 10.1111/bjd.15375
  • Valko PO, Bassetti CL, Bloch KE, Held U, Baumann CR. Validation of the Fatigue Severity Scale in a Swiss Cohort. Sleep. 2008;31(11):1601-1607.
  • Krupp LB, et al The Fatigue Severity Scale. Application to patients with multiple sclerosis and systemic lupus erythematosus. Arch Neurol 1989; 46:1121– 3.