extent, disability also influenced career, school and relationships with friends. Several daily activities were adversely affected by psoriasis, including clothing choice (54%), the need for more baths (45%), washing/changing clothes more often (40%), sport activities (38%), sleep disorders (34%) inhibiting work/school activities (27%), sexual difficulties (27%) and social relations (26%). A study conducted in Malaysia showed similar results, with only 5.6% of patients reporting that psoriasis had no effect on their QoL (22). A study conducted in Germany also found that psoriasis had a negative impact on QoL for the majority of patients. Only 15.2% reported that psoriasis had no effect on their QoL (23). However, it is important to note that in many studies, the correlation of impaired QoL scores with current clinical severity is low, indicating the impact of psoriasis on the individual goes beyond the apparent severity of skin lesions (141). Additionally, stigmatization and QoL burden associated with psoriasis can have a sustained effect over the course of a patient’s lifetime. The chronic disability caused by psoriasis is referred to as the “cumulative life course impairment of psoriasis” (CLCI) (20). CLCI is a key concept of psoriasis care because it indicates that this chronic disease, which can stretch over the period from childhood to old age, can lead to irreversible burden and lost opportunities. Thus, even in the absence of life-threating conditions or physical scarring, there is an urgent need for early intervention and evidence-based psoriasis treatment in order to avoid long-term suffering, disease progression and escalation of CLCI. In practice, indicators for patients at risk of CLCI can be detected, patients treated and potential CLCI prevented (142). Studies on the impact of psoriasis on QoL differ so dramatically in terms of methodology, that it is not possible to compare them accurately. QoL assessment is carried out using different scales and data are obtained using different tools (for example, self-administered questionnaires, telephone interviews, physician completed questionnaires) in various age and ethnic groups. Nevertheless, regardless of the methods used, there is considerable and uniform agreement in the literature that psoriasis leads to impairment of HRQoL. Moreover, in almost all clinical studies, HRQoL has improved with effective therapy (31). HRQol is also associated with the patient satisfaction of treatment (143). Of course, factors affecting psoriasis-associated disability may differ from patient to patient. Furthermore, the impact of psoriasis on an individual can vary over time. Population studies, nevertheless, offer a general insight into the factors that affect the QoL of people with psoriasis. Dai, 26, China, suffers from erythrodermic psoriasis and pustular psoriasis. Dai has never entered any formal employment. He now sells honey online, but still has to rely on financial assistance from his parents for living and treatment. In 2015 when his mother took him to hospital, they were turned away by taxi drivers on their way and also by innkeepers. Source: National Psoriasis Foundation, United States. Global report on psoriasis 21 Chapter 4. Improving the quality of care for people with psoriasis Principles of psoriasis management Psoriasis is by nature a chronic, incurable disease with an unpredictable course of symptoms and triggers. The consequence is often life-long treatment, therefore, all treatments must meet high quality criteria that are not only efficacious, but also safe over long periods. As the cause of psoriasis is still unknown, treatment is only available to control symptoms. Treatments include a range of topical and systemic therapies as well as phototherapy. It also involves treatment for reducing pain and disability from arthritis and other manifestations. Care for patients with psoriasis requires more than management of the skin lesions and joint involvement. The complexity of psoriasis means that prescribing drugs in isolation is insufficient to control the disease and a holistic, whole person approach to care is needed. Management of psoriasis also includes screening for associated diseases such as hypertension, dyslipidemia, diabetes mellitus and cardiovascular disorders as well as their complications