measure is an important element in assessing the advancement of the disease and its impact on patients’ health and well-being. QoL tools estimate the impact of the disease on the physical, mental, functional and social wellbeing from the patients’ own perspectives. The Dermatology Life Quality Index (DLQI), despite methodological limitations, is currently the most frequently used method of evaluating QoL for patients with different skin conditions. HRQoL is significantly impaired in patients with psoriasis. Factors such as disease severity, gender, age, anatomical sites of lesion, involvement of comorbidity (e.g. arthritis) and psychological distress can all be associated with reduced HRQoL in people with psoriasis. Burden from treatment and time needed for daily treatment are also major predictors of reduced HRQoL (139). Several studies showed evidence of a higher impact on QoL for females (139), whereas other studies have not found this difference. By contrast, an Iranian study on psoriasis patients showed that the negative impact on patients‘ QoL was higher for men than women (DLQI 11.0 versus 7.0) (21). The study also noted that the impact on QoL increased with the number of areas involved by the disease. The highest negative impact on QoL Jimmy, United States of America, suffers from severe psoriasis affecting 90% of his body. He is currently homeless, after losing his ability to work from his painful psoriatic plaques affecting his hands. He has been denied a bed in a shelter because the staff were concerned his skin lesions were contagious. Jimmy currently lacks any effective treatment and struggles daily to not only provide for himself, but treat his painful skin. Source: National Psoriasis Foundation, United States. Astrid, female, 57, Netherlands: “Having a serious skin disease at a young age is very difficult. Having psoriasis means that in the classroom no one wants to sit next to you. Having psoriasis means never to be invited to a birthday party and nobody wants to come to your birthday party. Having psoriasis means not being allowed to join the swimming lessons. Having psoriasis means not to be able to join a sports club etcetera. ... I fell in love with a nice man. He knew about psoriasis, because of his whole family suffered from psoriasis. After we married, we decided not to have children. We both have a sincere psoriasis and we don’t want to give this to a child. We didn’t want risk a child having a terrible life. This was very difficult to decide. Having no children means that you never have children in your house. No friends coming by, no children in law, no grandchildren. We have no people around the house and are just two people sitting at the Christmas dinner. Finding a job was very difficult. People suffering from psoriasis are not wanted. Another problem was finding a house. We wanted to buy a house, but because of the chronic disease, we were not able to get a mortgage. Now we have to pay a very high rental price, which means we are not able to go on holidays etc. … There are also practical difficulties. When I want to go to a hairdresser it always gives big problems. Hairdressers don’t like people with psoriasis. When I go shopping for clothes, I am not allowed to try some. When you go to the fitting room, you are not allowed to give the clothes back if they don’t fit. You have to buy them, even if they don’t fit. … If I had no psoriasis, my life was probably complete different: Maybe we lived in a nice house. Probably we had a family: children and grandchildren. Maybe I had the job that I was educated for. Without psoriasis we could have a normal life.” Source: Psoriasis Vereniging Nederland. Global report on psoriasis 19 was observed when the neck/décolletage region or hands were involved, and the lowest when the groin was involved. A study conducted on a large population of European psoriasis patients showed that the overall impact of psoriasis increased in combination with the severity of the disease (105). Psoriasis was a significant problem for 15% of patients with mild psoriasis, 23% with moderate psoriasis and 51% with severe psoriasis. In addition, 48% of patients reported that their disability due to psoriasis had a modest impact on activities of daily living. To a lesser