study (119). Global report on psoriasis 17 Influences from the workplace In the workplace, psoriasis may be triggered or aggravated by mechanical or other physical impact on unprotected body locations (120). In patients who claimed occupational hand dermatitis, psoriasis was found to be the cause of the disease in 3.8% (121)–6.5% (122) of cases. Special gloves and other personal protective equipment may reduce lesions and enable the person to continue working, which otherwise may be jeopardized (121,123). Social participation Psoriasis can affect relationships at home, school or work as well as sexual relationships and thus reduce QoL and cause psychological strain (15,17–19,32,124–128). Patients are frequently stigmatized and excluded from normal social environments, including schools, workplaces and swimming pools. As a result, they often avoid social activities and commonly report experiencing loneliness, isolation, feelings of being unattractive and frustration. A study conducted in the United States evaluated which spheres of patients’ lives suffered most (7). Seven impact areas were considered: emotional (mood, feelings); social (friends, activities); the family (activities, responsibilities); professional (work, career); physical functioning; sexual intimacy; and educational life. The results showed that 98% of patients reported that psoriasis impacted on their emotional life, 94% on their social life, 70% on family life, 68% on their professional career, 38% on physical functioning, 17% on sexual intimacy, and 21% on their educational life. These values were all higher for patients with psoriatic arthritis. The lost opportunities and the burden from disease over a significant portion of a lifetime can be cumulative and in many cases are irreversible. Socioeconomic burden In patients with psoriasis, functional impairment, lost opportunities in professional life and elevated economic burden for treatment expenses can add to significant socioeconomic burden on an individual level (129–131). The costs of psoriasis are significant for both patients and the health-care system. The annual cost of psoriasis in the United States was estimated at US$ 11.5 billion in 2008, with patient outof-pocket costs accounting for 55% of the total direct costs of the disease (132,133). Survey data from the United States indicate that psoriasis patients pay on average US$ 2528 out-of-pocket each year on psoriasis care, 34% of which is on prescription and over-the-counter medicines (134). In Switzerland, outof-pocket expenses for ambulatory care per patient in 2005 ranged from CHF 600–1100 per year for mild psoriasis to CHF 2400–9900 for severe psoriasis (135). Gary, with a genuine passion for swimming, has been a chronic patient of psoriasis since 23. Gary was not admitted to public swimming pools as swimmers made complaints to lifeguards. Even though the lifeguards know that psoriasis isn’t contagious and won’t be transmitted through water, they couldn’t help but settle the situation by asking him to leave. … Moderate sunbathing can benefit psoriasis. Gary headed to a public park for sunbathing on a Sunday morning. When Gary revealed his skin, with red patches on the upper trunk, the mother of a little girl walked away with her daughter. Gary tried to explain to her that one couldn’t catch psoriasis or spread it to others, yet the young lady turned a deaf ear to what he said and refused to believe it. Source: © Hong Kong Psoriasis Patients Association. Global report on psoriasis 18 Inability to work due to psoriasis increases with psoriasis severity. In one German study, employed patients lost a mean of 4.9 working days per year due to psoriasis (23). For severe psoriasis, the incidence of hospitalization is almost twofold higher than for mild psoriasis (136). In addition, patients suffering from severe disease report a greater number of days absent from work or school due to psoriasis (136). On the societal level, psoriasis, due to its high prevalence and marked direct and indirect costs, can result in considerable economic burden for tax payers, patients and society in general (129,131,137,138). Measuring the impact of psoriasis on quality of life In addition to the evaluation of clinical manifestations, a health-related quality of life (HRQoL)