therapies (168). Recent advances in biologic agents have considerably expanded the treatment options for patients with psoriasis, however, the prices of these newer treatments are higher than traditional systemic medications and phototherapy (169,170). A cost analysis of systemic therapies conducted between 2000 and 2008 revealed that medication prices are increasing at a rate greater than that of general inflation (170). Given the chronicity of psoriasis, these expenses compound over the duration of treatment. Whether the cost is born by the patients themselves or by governments and insurance funds, the high cost of therapies for chronic conditions like psoriasis adds a huge burden to overall health expenditure. Manufacturers need to work with purchasers and regulators to provide these therapies at lower prices, especially for newer systemic therapies. Even the costs of generic topical therapies and cheaper systemic treatments such as methotrexate and cyclosporine can be barriers to the optimal management of psoriasis in lower-resource settings (166). Difficulties with adherence Non-adherence to treatment is a barrier to quality care for people with psoriasis. Multiple recurrences, side-effects and cost of treatment can dishearten patients. This can lead to poor adherence to therapy and prevent patients from achieving the best possible results from treatment (162,163). Patient adherence is also negatively associated with dissatisfaction with treatment and psychiatric morbidity (143). Poor adherence is highest with topical therapy, but it is also a problem with systemic treatment that includes biologic agents (30). Low adherence is partly due to insufficient communication regarding instructions on how to use the drug, misperception of possible adverse events and mistaken expectations about the speed and degree of improvement. Male, South Africa: “I think the main problem that I faced was that the medical aid did not pay for certain treatments, and that became a very costly exercise to get my skin to clear up. This resulted in my family owing the dermatologist a hefty amount of money, because the medical aid stopped funding my treatment (without informing us in time). Eventually, I threw up my hands in despair, and basically, I gave up on my skin treatment. As a result of this, I think about 65–75% of my body is covered in scales.” Source: South Africa Psoriasis Association. Global report on psoriasis 26 Discrimination Discrimination against patients with psoriasis can directly affect their ability to access appropriate health care. In many communities, the belief that psoriasis is contagious can cause problems for patients in public places, including health-care facilities and pharmacies. Exclusion from work reduces the ability to pay for the requisite health care and inhibits full participation in society in a way that promotes their general well-being and a healthy lifestyle. Public misconceptions about psoriasis, for example, the myth that it is a contagious disease, results in exclusion of patients from the everyday life of their communities and fosters low self-esteem, depression and even suicide. What can be done? The negative impact of psoriasis on patients’ lives can be reduced in a number of key areas. These include: (i) ensuring that the treatment of skin diseases is included in universal health coverage schemes; (ii) carrying out campaigns and training aimed at increasing knowledge and awareness of psoriasis among health-care providers and society; (iii) increasing research into the etiology of psoriasis; and (iv) developing new therapies targeting the causes of the disease. Universal access to health services and essential medicines The most important step is to implement global commitments to achieve universal health coverage. Universal health coverage has been specifically included in the Sustainable Development Goals for 2030, approved by all United Nations Member States at a High-level Plenary Meeting of the General Assembly in New York on 25–27 September 2015. Member States agreed that they will achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential