More than Skin Deep – The Comprehensive Burden of Psoriasis

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Approximately 7.5 million people in the United States and over 125 million worldwide live with psoriasis.1,2 This chronic, immune-mediated inflammatory disease manifests as red, scaly plaques on the skin, but its impact extends well beyond the skin, affecting physical, emotional and social well-being.2-4

For individuals with psoriasis in high-impact sites (HIS)—e.g., the face, hands, feet, scalp and genitals—the burden can be especially profound.5,6 Even if the plaques are small in surface area, these areas can significantly disrupt daily activities and affect quality of life (QOL).5 However, traditional disease severity classification systems worldwide often fail to reflect this reality. As a result, individuals who experience significant discomfort, stigma and limitation may be classified, using body surface area (BSA), as having mild disease and receive treatment that may not adequately address their symptoms and may significantly affect QOL.5,6 This potential underdiagnosis of moderate disease can delay access to appropriate therapies and may contribute to long-term disease burden.5,6 Though international and country-specific dermatology and psoriasis organizations are working to implement more modernized guidelines, several hurdles have existed, ultimately hindering patient access to timelier, patient-centered care.

With a growing body of research showing that early intervention and effective treatment of psoriasis can reduce the long-term disease burden, improve outcomes and prevent disease progression or the onset of complications, it is critical to identify these barriers and ensure a standardized and nuanced disease severity classification system is fully employed to transform psoriasis diagnosis, management and care.

The Outdated and Inconsistent Classification Systems Worldwide

In the United States, conventional psoriasis severity classifications rely primarily on BSA, the Psoriasis Area and Severity Index (PASI), and the Physician Global Assessment (PGA).7 Under these criteria, clinicians classify individuals with less than 3% BSA involvement as having mild disease, even if their plaques appear in HIS.8 This narrow focus has resulted in a lower recognition of potential disease severity, where patients may not meet the numeric thresholds that would classify their psoriasis as severe but still experience significant physical and emotional effects.5,6

In contrast, European standards incorporate the Dermatology Life Quality Index (DLQI), offering a more holistic view of the impact of psoriasis on individuals. Clinicians classify mild disease as involving a BSA and PASI score of less than or equal to 10 and a DLQI score less than or equal to 10, whereas moderate to severe psoriasis is defined by a BSA or PASI score greater than 10 and a DLQI score above 10. Additionally, certain clinical features may upgrade a case from mild to moderate-to-severe, including major involvement of visible areas (e.g., face, hands), scalp or genital involvement, nail disease (onycholysis or onychodystrophy of at least two fingernails), severe itch leading to scratching and recalcitrant plaques.9

Guy Eakin, PhD, chief scientific and medical officer of the National Psoriasis Foundation (NPF), remarked, “When we define severity based solely on the extent of skin involvement, we risk ignoring the everyday challenges people face, especially when plaques affect sensitive or visible areas. We hear this from our community all the time. In our 2022 survey of over 4,000 individuals living with psoriasis, nearly half of those labeled with mild disease reported a meaningful impact on their quality of life.5 These lived experiences must play a larger role in how we define and address disease severity.”

The Real-Life Impact of Psoriasis and Psoriasis in High-Impact Sites

The disconnect between the traditional classification systems and lived experience is stark. Results of multiple studies, including analyses of large electronic health record data sets and multinational patient surveys, show that the location of psoriasis plaques can lead to notable psychosocial strain and treatment dissatisfaction, especially in those living with psoriasis in HIS.10,11 Data from the UPLIFT survey of 3,614 adults who self-reported a health care provider diagnosis of psoriasis and/or psoriatic arthritis revealed that more than 14% of individuals with special area involvement reported an “extremely large effect” on their quality of life compared with just 6.9% of those without.11

For Takieyah Mathis, a passionate advocate with NPF, her experience* living with psoriasis provides a real-life example of these findings and the urgent need to modernize care. The rapid onset of her plaques on places such as her scalp led to significant hair loss and her diagnosis in the hospital – an experience that profoundly affected her confidence, emotional well-being and professional life. The thick, painful plaques extended to highly visible areas, including her face, exposing her to repeated stigma in the workplace, including modeling and the fast-food industry.

“What we see in clinical practice often doesn’t align with the current disease severity classification system and fails to reflect the true burden of the disease, especially when symptoms appear in high-impact sites. Individuals like Takieyah, who have psoriasis in highly visible areas, can experience a profound impact on their quality of life. It’s a powerful reminder that our classification systems need to evolve for all those living with psoriasis,” noted Warren Winkelman, MD, PhD, a board-certified dermatologist and the global medical unit head for dermatology at Takeda.

Modernized Guidelines Offer a Path Forward

Recognizing this disconnect, the International Psoriasis Council (IPC) and the NPF, both key advocates for advancing standards of care for psoriatic disease, have led efforts to modernize how disease severity is defined, with support from the broader psoriasis community. In 2020, the IPC published a global consensus statement on psoriasis disease classification that recommends systemic therapy for individuals with psoriasis who meet any of the following criteria: BSA greater than 10%, HIS involvement (e.g., face, palms, soles, genitals, scalp or nails) and inadequate response to topical treatments.12

“The traditional classification system brackets patients with psoriasis into arbitrary BSA and PASI ranges that don’t always correlate to how psoriasis might negatively affect a person’s entire life. This is especially true when plaques appear in HIS, which can be quite disabling,” said Bruce Strober, MD, PhD, FAAD, board president of IPC and clinical professor of dermatology at Yale University School of Medicine. “Our objective with the updated IPC consensus was to simplify the classification of disease severity, making it applicable to current clinical use and future clinical trial endpoints. By sharing an updated classification system, we hope to remove barriers to biologic and systemic therapies for individuals in need, particularly those with HIS involvement.”

The Adoption Gap

Many country-specific organizations have readily adopted these practical and simplified IPC classifications. In the United States, the NPF and the American Academy of Dermatology are jointly advocating for the adoption of the IPC consensus statement into the next guidelines update. In Australia, the Australasian College of Dermatologists revised its national guidelines in 2023 to recommend systemic therapy for adults meeting at least 1 of the following: BSA greater than 10%, PASI greater than 10, PGA greater than 2 (scored on a scale of 0-4), HIS involvement, severe pruritus leading to excoriation, DLQI greater than 10 and failure of topical therapy.13 Similarly, in 2024, the Korean Society for Psoriasis recognized patients with PASI scores between 5 and 10 as candidates for systemic therapy when HIS involvement is present.14 Most recently, in January 2025, the Japanese Dermatological Association reached consensus to include criteria for physicians to better identify psoriasis and limited skin involvement who would benefit from systemic therapy, including those where topical therapy failure may indicate a move to systemic treatment.15

“While the adoption of these guidelines is significant progress and reflects a more holistic and patient-centered approach, evolving how we define psoriasis severity isn’t just an academic exercise. There are real-world implications for drug labeling, clinical trial design and treatment access. Historical definitions are deeply embedded in regulatory systems and entrenched in clinical trial inclusion criteria, so revising those frameworks isn’t simple,” shared Eakin.

The Road Ahead: Improving Care for People Living With Psoriasis

Psoriasis is more than skin deep; it’s a chronic systemic disease that demands an updated approach to classification. Redefining severity is not simply about semantics; it’s about ensuring that every patient—regardless of how extensively and visibly the skin is affected—has access to timely, appropriate and effective care.

Reflecting on the future of psoriasis research, Winkelman noted, “There have been numerous advancements in our understanding of psoriasis since the development of these classification systems. However, we must go beyond the surface and integrate the patient experience, applying that understanding to our clinical development approach. By working together to redefine how psoriasis is classified, dermatologists and advocacy groups can ensure earlier intervention and potentially reshape the future of psoriasis care to better serve the needs of patients.”

Strober concluded, “Redefining severity is only the first step. With the IPC consensus statement and country-specific guidelines in circulation, it is now critical to translate these definitions into everyday practice. That means building alignment across clinical care, clinical trial protocols and professional education. By including lower BSA values and individuals with HIS psoriasis, we may see improved outcomes for those who need it most.”

As new data, patient insights and emerging biomarkers deepen the understanding of the risks of disease progression, the psoriasis community has a significant opportunity to build a framework that will address the disease’s full scope and stand the test of time.

*Individual experiences may vary.

References

  1. Armstrong AW, Mehta MD, Schupp CW, et al. Psoriasis prevalence in adults in the United States. JAMA Dermatol. 2021;157(8):940-946. doi:10.1001/jamadermatol.2021.2007
  2. Zhang Y, Dong S, Ma Y, Mou Y. Burden of psoriasis in young adults worldwide from the global burden of disease study 2019. Front Endocrinol (Lausanne). 2024;15:1308822. doi:10.3389/fendo.2024.1308822
  3. Raam L, Hartmane I, Valiukevičienė S, et al. Disease severity, treatment patterns, and quality of life in patients with moderate-to-severe psoriasis routinely managed with systemic treatment: results of the CRYSTAL observational study in Central and Eastern European countries. Front Immunol. 2024;15:1410540. doi:10.3389/fimmu.2024.1410540
  4. Parisi R, Iskandar IYK, Kontopantelis E,et al. National, regional, and worldwide epidemiology of psoriasis: systematic analysis and modelling study. BMJ. 2020;369:m1590. doi:10.1136/bmj.m1590.
  5. Blauvelt A, Gondo GC, Bell S, et al. Psoriasis involving special areas is associated with worse quality of life, depression, and limitations in the ability to participate in social roles and activities. J Psoriasis Psoriatic Arthritis. 2023;8(3):100-106. doi:10.1177/24755303231160683
  6. Strober B, Duffin KC, Lebwohl M, et al. Impact of psoriasis disease severity and special area involvement on patient-reported outcomes in the real world: an analysis from the CorEvitas psoriasis registry. J Dermatolog Treat. 2024;35(1):2287401. doi:10.1080/09546634.2023.2287401
  7. Armstrong AW, Gondo GC, Merola JF, et al. Defining on-treatment remission in plaque psoriasis: a consensus statement from the National Psoriasis Foundation. JAMA Dermatol. Published online June 18, 2025. doi:10.1001/jamadermatol.2025.1625
  8. Yee D, Armstrong AW. Re-classification of psoriasis severity: perspectives and controversy. J Psoriasis Psoriatic Arthritis. 2022;7(1):7-8. doi:10.1177/24755303211071033
  9. Nast A, Spuls P, Dressler C, et al. EuroGuiDerm Guideline for the systemic treatment of psoriasis vulgaris;January 2024. Accessed July 14, 2025.https://www.guidelines.edf.one/uploads/attachments/clrf2t72k3ttodtjrokdem0cy-0-euroguiderm-pso-gl-draft-2024.pdf
  10. Griffiths CEM, Jo SJ, Naldi L, et al. A multidimensional assessment of the burden of psoriasis: results from a multinational dermatologist and patient survey. Br J Dermatol. 2018;179(1):173-181. doi:10.1111/bjd.16332
  11. Lebwohl M, Langley RG, Paul C, et al. Evolution of patient perceptions of psoriatic disease: results from the Understanding Psoriatic Disease Leveraging Insights for Treatment (UPLIFT) survey. Dermatol Ther (Heidelb). 2022;12(1):61-78. doi:10.1007/s13555-021-00635
  12. Strober B, Ryan C, van de Kerkhof P, et al. Recategorization of psoriasis severity: Delphi consensus from the International Psoriasis Council. J Am Acad Dermatol. 2020;82(1):117-122. doi:10.1016/j.jaad.2019.08.026
  13. The Australasian College of Dermatologists. Consensus Adaptation: Treatment Goals for Moderate-to-Severe Psoriasis in Paediatric and Adult Australian Patients. May 2024. Accessed July 8, 2025. https://www.dermcoll.edu.au/wp-content/uploads/2024/05/ACD-Consensus-Adaptation-Psoriasis-May-2024.pdf
  14. Kim C. Psoriasis experts’ consensus sets new treatment standards by reflecting patients’ quality of life. Korea Biomedical Review. December 30, 2024. Accessed July 8, 2025. https://www.koreabiomed.com/news/articleView.html?idxno=26164
  15. Morita A, Okubo Y, Imafuku S, et al. Expert consensus on systemic therapy for plaque psoriasis with limited skin involvement in Japan: results from a DELPHI study. J Dermatol. 2025;52(1):56-66. doi:10.1111/1346-8138.17444

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