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Analysis of health care and actual needs of patients with psoriasis: a survey on the Italian population

  • Emma Altobelli1Email author,
  • Mara Maccarone2,
  • Reimondo Petrocelli1,
  • Ciro Marziliano1,
  • Alberto Giannetti3,
  • Ketty Peris4 and
  • Sergio Chimenti5
BMC Public Health20077:59

DOI: 10.1186/1471-2458-7-59

Received: 12 August 2006

Accepted: 21 April 2007

Published: 21 April 2007

Abstract

Background

Over recent years the public health system has shown increasing interest in patients' views for use as guideline criteria in evaluating the quality of assistance above all for those patients with chronic diseases. Hence the interest in psoriasis, which is a chronic disease frequently associated with diabetes mellitus, hypertension, obesity, and cardiovascular diseases. The aims of our study were to describe clinic characteristics of patients with psoriasis, the quality of the assistance perceived by patients arrived at outpatients clinics and the information received, in order to identify areas in Italy requiring improvement.

Methods

1954 patients, aged between 18 and 85 years, were consecutively enrolled at outpatients clinics across 21 Italian provinces over the period December 2004 – January 2006. A standardized questionnaire was developed in collaboration with an Italian Association of Psoriatic Patients (A.DI.PSO) and tested in a pilot study. The questionnaire was divided into three sections: the first section included social, demographic and individual variables; the second concerned the quality of the assistance perceived by the patients at public dermatologic clinics and the third focused on the need of information requirements of patients with psoriasis. The χ2 test was used to estimate the association between the categorical variables under study. Kruskal-Wallis test was applied to the interval and ordinal variables.

Results

The presence of psoriatic arthritis was reported in 26.0% of patients. Associated chronic diseases included depression (15.4%), hypertension (13.3%), obesity (8.9%) and type 2 diabetes mellitus (7.3%). The study highlighted the need of improvements of health care services at public dermatologic clinics especially in overcoming architectonic barriers and reducing appointment wait-times, particularly in South Italy. However, patients reported a positive relationship with Health System employers due to the confidentiality. This positive impression was confirmed by the observation that dermatologists were considered the best source of information about therapies on psoriasis.

Conclusion

Our study allowed to identify critical aspects which could be tackled through initiatives with the aim of improving these emerged needs.

Background

Psoriasis is a chronic disease with a different prevalence between countries varying from 0.8 to 3.1% [1, 2]; psoriatic arthritis (PsA) has been found to be associated with skin lesions in 20–34% of patients [35]. Psoriasis has a significant involvement on patients' quality of life and their social and family relationships [6, 7]. In addition, psoriasis has proven to be frequently associated with chronic extra-cutaneous diseases such as diabetes mellitus (DM), hypertension, obesity, and cardiovascular diseases [810].

Over recent years, the public health system has shown increasing interest in the quality of medical care as well as in the patients' degree of satisfaction which in turn represents a useful indicator of the quality of health care. In fact, it is known that a positive perception of medical services by the patients, a good relationship between patients and medical staff and a comfort of the surroundings improve the doctor-patient relationship leading to enhanced therapeutic compliance, better quality of the health service and saving of economical resources. Furthermore, the level of information given to the patient about their disease may improve disease management and hence quality of life.

The aims of our study were to describe: i) the clinic characteristics of patients with psoriasis, ii) the quality of medical care as perceived by the patients at public dermatologic clinics, and iii) the information received by the patient, in order to identify areas in Italy with priority need of improvement.

Methods

Study population

The study population consisted of 1954 patients, aged 18–85 years, who were consecutively enrolled into the study over the period 1st December 2004 – 31st January 2006: 991 patients were males with an average age of 48.4 years (standard deviation [sd] 15.0) and 963 were females with an average age of 47 years (standard deviation [sd] 15.0). Patients attended the public dermatologic clinics taking part in the project across 21 Italian provinces: Ascoli Piceno, Bari, Benevento, Bologna, Brindisi, Brescia, Catania, Catanzaro, Cesena-Forlì, Firenze, L'Aquila, Lucca, Milano, Modena, Napoli, Palermo, Padova, Prato, Reggio-Calabria, Roma, Verona. To improve the efficiency of the sampling plan, stratified sampling by province was used: to estimate the sampling dimension the following parameters were used: sample error E = 0.025, the event occurrence proportion p = 0.5 (in the case of maximum variability), probability 1-α = 0.95.

Data collection

A standardized questionnaire, developed in close collaboration with an Italian Association of Psoriatic Patients (Associazione per la Difesa dei Pazienti Psoriasici, A.DI.PSO) and tested in a pilot study, was used for data collection. The questionnaire was explained by trained personnel to the patients when they underwent routine visits at dermatologic clinics; patients completed the questionnaire singularly and autonomously. The questionnaire was divided into three parts: the first section concerned patients' social, demographic and case history variables such as smoking and alcohol consumption, associated diseases such as depression, hypertension, type 2 DM and obesity. All diagnoses were reported by patients: they were asked to provide the age of psoriasis (defined as the age of patients at the first dermatologic visit for psoriasis) while diagnoses of associated disease was conceivably established by other specialists but not verified by us. The second part focussed on the quality of the assistance perceived by the patients at public dermatologic clinics and took into account parameters such as the accessibility of the dermatologic clinic (e.g. the presence of architectonic barriers), the programming of routine visits, the time spent in the waiting room of the clinic, the quality of the waiting room (e.g. comfort, privacy etc.), and the third part looked at the information needs of the patients.

Informed consent was obtained from all subjects. All of the subjects who were invited to participate in the study agreed to do so.

Statistical analysis

The data collection was analyzed by grouping the patients in the participating provinces into three geographical areas: North, Centre and South.

The χ2 test was used to estimate the association between the categorial variables under study. Kruskal-Wallis test was applied to the interval and ordinal variables. A value of p < 0.05 was considered statistically significant. SAS software was used for the statistical analyses [11].

Results

The results of the first section of the questionnaire are summarized in tables 1 2 3. No differences were found for marital status between the three areas: North, Centre and South Italy. However a statistically significant difference was detected concerning education (p < 0.0001). Out of 1947 patients interviewed, 2.7% had not received education. The lower level of education was observed in the South whilst the highest level of education was found in the Centre (p = 0.0006). A statistically significant difference was also found for occupational status; the highest level of unemployment was detected in the South (p < 0.0001). Our results show that the Centre Italy has the highest number of working days lost compared to the North and South Italy (p = 0.002).
Table 1

Distribution of social and demographic variables in the three Italian areas (North, Centre and South)

 

North

Centre

South

p

 

No.

%

No.

%

No.

%

 

Marital status (total no. cases 1954)

Never married

203

28.5

194

31.5

162

25.9

0.09

Married

510

71.5

422

68.5

463

74.1

 

Education (total no. cases 1947)

No education

17

2.4

7

1.1

28

4.5

0.0006

Primary school

105

14.7

73

11.7

124

19.8

 

Junior high school

175

24.6

154

25.1

140

22.4

 

High school

301

42.2

286

46.5

244

39.1

 

University

115

16.1

96

15.6

82

14.2

 

Occupational status (total no. cases 1954)

Manual worker

128

18.0

97

15.8

97

15.5

< 0.0001

Office worker

150

21.0

149

24.2

132

21.1

 

Professional

165

23.1

122

19.8

114

18.2

 

Unemployed

17

2.4

32

5.2

68

11.0

 

Houseworker

62

8.7

57

9.2

54

8.6

 

Retired

118

16.6

102

16.6

77

12.3

 

Other

73

10.2

57

9.2

83

13.3

 

Working days lost (total no. cases 1235)

1–7

205

46.6

136

34.6

176

43.8

0.002

8–14

82

18.6

85

21.6

95

23.6

 

15–21

35

8.0

42

10.7

41

10.2

 

22–28

16

3.6

19

4.8

16

4.0

 

29–35

32

7.3

59

15.1

29

7.2

 

> 35

70

15.9

52

13.2

45

11.2

 
Table 2

Distribution of smoking and alcohol consumption in the 3 Italian areas

Age-group (years)

20–39

40–59

> = 60

Italy

North No. %

Centre No. %

South No. %

p

North No. %

Centre No. %

Suth No. %

p

North No. %

Centre No. %

South No. %

p

Cigarettes per day (total no. of cases: 759)

< 5

14 14.1

5 4.6

16 23.5

0.0005

6 6.1

18 15.4

12 9.2

0.11

6 11.8

3 13.6

9 15.0

0.90

5–15

61 61.6

58 53.7

24 35.3

 

43 43.9

42 35.9

55 42.0

 

21 41.2

11 50.0

23 38.3

 

16–20

10 10.1

23 21.3

11 16.2

 

31 31.6

33 28.2

28 21.4

 

10 19.6

4 18.2

9 15.0

 

> 20

14 14.2

22 20.4

17 25.0

 

18 31.4

24 20.5

36 27.4

 

14 27.4

4 18.2

19 31.7

 

Wine consumption (total no. of cases :857)

1–2 glasses/day

56 82.3

56 80.0

36 83.7

0.87

99 72.3

104 68.9

98 76.0

0.42

70 66.0

57 83.8

69 81.2

0.001

> 2 glasses/day

12 17.7

14 20.0

7 16.3

 

38 27.7

47 31.1

31 24.0

 

36 34.0

11 16.2

16 18.8

 

Beer consumption (total no. of cases: 233)

1–2 glasses/day

36 87.8

33 91.7

16 84.2

-

28 90.3

20 83.3

34 82.9

-

11 91.7

5 100.0

20 83.3

-

> 2 glasses/day

5 12.2

3 8.3

3 15.8

 

3 9.7

4 16.7

7 17.1

 

1 8.3

0 0.0

4 16.7

 

Spirits (total no. of cases: 178)

1 drink/day

12 70.6

13 81.2

4 30.8

0.01

16 72.7

17 51.5

23 67.6

0.21

17 85.0

4 80.0

9 50.0

-

> 1 drink/day

5 29.4

3 18.8

9 69.2

 

6 27.3

16 48.5

11 32.4

 

3 15.0

1 20.0

9 50.0

 

P values were calculated for the items whose expected values were more than 5 for 80% of cells and none expected value less than 1.

Table 3

Distribution of extra-cutaneous disease associated with psoriasis in the 3 Italian areas

 

Males (total no. of cases: 991)

Females (total no. of cases: 963)

Disease category (ICD§ code number)

North No. (%)

Centre No. (%)

South No. (%)

p

North No. (%)

Centre No. (%)

South No. (%)

p

Depression (296)

Present

34 (8.6)

56 (18.7)

43 (14.6)

 

59 (18.7)

53 (16.8)

57 (17.2)

 

Absent

363 (91.4)

244 (81.3)

251 (85.4)

0.0004

257 (81.3)

263 (83.2)

274 (82.8)

0.81

Myalgia (729.1)

Present

0 (0.0)

2 (0.7)

3 (1.0)

 

0 (0.0)

6 (1.9)

7 (2.1)

 

Absent

397 (100.0)

298 (99.3)

291 (99.0)

-

316 (100.0)

310 (98.1)

324 (97.9)

-

Obesità (278)

Present

39 (9.8)

23 (7.7)

27 (9.2)

 

29 (9.2)

32 (10.1)

34 (10.3)

 

Absent

358 (90.2)

277(92.3)

267 (90.8)

0.61

287 (98.8)

284 (89.9)

297 (89.7)

0.88

Type 2 DM (250)

Present

29 (7.3)

15 (5.0)

21 (7.19)

 

23 (7.3)

12 (3.8)

43 (13.0)

 

Absent

368 (92.7)

285 (95.09)

273 (92.9)

0.42

293 (92.7)

304 (96.2)

288 (87.0)

< 0.0001

Hypertension (401)

Present

71 (17.9)

52 (17.3)

38 (12.9)

 

41 (13.0)

24 (7.6)

35 (10.6)

 

Absent

326 (82.19

248 (82.7)

256 (87.1)

0.18

275 (87.0)

292 (92.4)

296 (89.4)

0.08

Heart disease(410–414)

Present

7 (1.8)

2 (0.7)

14 (4.8)

 

1 (0.3)

0 (0.0)

7 (2.1)

 

Absent

390 (98.2)

298 (99.3)

280 (95.2)

0.003

315 (99.7)

316 (100.0)

324 (97.9)

-

Herpes virus (054)

Present

5 (1.3)

11 (3.7)

10 (3.4)

 

18 (5.7)

15 (4.7)

10 (3.0)

 

Absent

392 (98.7)

289 (96.3)

284 (96.6)

0.08

298 (94.3)

301 (95.3)

321 (97.0)

0.25

Other *

Present

2 (0.5)

4 (1.3)

10 (3.4)

 

6 (1.9)

9 (2.8)

6 (1.8)

 

Absent

395 (99.5)

296 (98.7)

284 (96.6)

0.01

310 (98.1)

307 (97.2)

325 (98.2)

0.61

§ ICD = IX International Classification Diseases

* iritis (364), lupus (710.0)

P values were calculated for the diseases whose expected values were more than 5 for 80% of cells and none expected value less than 1.

Overall, 45.4% of the patients were smokers; 45.2% drunk wine, 11.9% beer and 9.1% spirits. The distribution of smokers and drinkers was analyzed for the three geographical areas (table 2). The heaviest smokers (> 20 cigarettes per day) were in the South in the 20–39 age group (25.0%, p = 0.0006). There was no significant difference between the three areas in the group of patients 40–59 years of age. The heaviest wine consumption (> 2 glasses/day) in those that drink was in the North in the ≥ 60 age group (p = 0.001). Beer (> 2 glasses/day) and spirit (< 2 glass/day) consumption was greater in South Italy in the 20–39 age group being 15.8% and 69.2%, respectively.

PsA was reported in 26.0% of patients. The most frequent extra-cutaneous diseases associated with psoriasis were depression (15.4%), hypertension (13.3%), obesity (8.9%) and type 2 DM (7.3%). PsA was associated with obesity in 36% of cases (p = 0.0007), type 2 DM in 34% of cases (p = 0.03), hypertension in 32% of cases (p = 0.02) and depression in 30% of cases although the latter result was not statistically significant. Table 3 shows the distribution of the extra-cutaneous diseases associated with psoriasis by stratified area and gender. The distribution of depression differed between North, Centre and South Italy in men with the highest percentage being 18.7% (p = 0.0004) in Centre Italy. No significant distribution was observed for hypertension between North, Centre or South or in men or women. Type 2 DM in female patients was higher in the South (13.0%, p = 0.02).

The results of the second part of the questionnaire concerning the quality of medical services perceived by the patients at public dermatologic clinics are summarized in table 4. Better access in terms of lack of architectonic barriers was registered in the North as compared to the South (p < 0.0001). The number of routine visits was higher in the North (every 30 days) than in the South (once a year) (p < 0.0001). However patients in the North changed dermatologic clinics more frequently than patients in the South (p < 0.0001). Patients attending dermatologic clinics in the North were more satisfied by levels on accessibility, time (minutes) spent in the waiting room and quality of the time in the waiting room (p < 0.0001). In addition, patients attending dermatologic clinics in the North were more satisfied by levels of confidentiality and privacy and by the levels of helpfulness and courtesy of the health system personnel with respect to patients attending clinics in the South (p < 0.0001). The results concerning the patients' knowledge about psoriasis and need of information are summarized in table 5. Patients in the North were more satisfied with the explanation of their disease by their dermatologist and general practitioner (p < 0.0001). There was also a statistically significant difference between the three geographical areas as far as the information source on disease treatment was concerned. Patients living in the Centre felt they needed more information concerning therapy (p < 0.0001). Notably, only 29.5% of patients were aware of patients' rights and there was no significant difference between North, Centre and South Italy. Finally, the knowledge of homeopathy and herbal products was more widespread in the South (p < 0.0001) as was the knowledge of therapies such as acupuncture and the use of phototherapy (p = 0.005).
Table 4

Distribution of quality of the assistance perceived by patients in the 3 Italian areas

Item

Total responders

North

Centre

South

p

 

No

%

No

%

No

%

No

%

 

Clinic accessibility

Bad

1813

92.8

50

7.5

48

8.5

134

22.9

< 0.0001

Poor

  

66

9.9

109

19.4

115

19.7

 

Good

  

289

43.4

229

40.7

236

40.4

 

Very good

  

261

39.2

117

31.4

99

17.0

 

Routine visits every

15 days

1792

91.7

36

5.5

25

4.4

36

6.3

< 0.0001

30 days

  

197

30.1

84

14.9

100

17.5

 

2–4 months

  

187

28.6

199

35.2

146

25.4

 

5–7 months

  

117

17.9

140

24.8

125

21.8

 

1 year

  

117

17.9

117

20.7

166

29.0

 

Length of time at the same clinic

< 6 months

1792

91.7

158

23.4

111

19.8

110

19.8

0.01

12 months

  

136

20.1

98

17.5

75

13.4

 

18 months

  

112

16.6

78

13.9

84

15.1

 

24 months

  

69

10.2

100

17.9

116

20.8

 

30 months

  

49

7.3

42

7.5

36

6.5

 

> 30 months

  

151

22.4

131

23.4

136

24.4

 

Time (minutes) spent in the waiting room

< 15'

1856

95.0

194

28.5

113

19.6

138

23.0

< 0.0001

15–30'

  

316

46.5

249

43.2

184

30.7

 

35–60'

  

139

20.4

114

19.8

153

25.5

 

> 60

  

31

4.6

100

17.4

125

20.8

 

Quality of the time spent in the waiting room

Unacceptable

1834

93.9

28

4.2

68

12.0

119

20.1

< 0.0001

Poor

  

84

12.4

120

21.2

128

21.7

 

Good

  

439

64.8

271

47.9

290

49.1

 

Very good

  

126

18.6

107

18.9

54

9.1

 

Confidentiality and privacy of the clinic personnel

Poor

1873

95.9

34

4.9

101

17.2

149

25.0

< 0.0001

Good

  

293

42.5

236

40.1

259

43.5

 

Very good

  

362

52.6

251

42.7

188

31.5

 

Helpfulness and courtesy of the clinic personnel

Excellent

1868

95.4

326

47.0

261

44.8

177

29.9

< 0.0001

Good

  

306

44.1

194

33.3

196

33.2

 

Sufficient

  

49

7.1

103

17.7

126

21.3

 

Poor

  

13

1.8

25

4.2

92

15.6

 

Overall level of services offered by the public health system

Unsatisfactory

1831

93.7

36

5.2

105

18.4

165

28.8

< 0.0001

Satisfactory

  

334

48.6

259

45.4

267

46.5

 

Very good

  

317

46.2

306

36.2

142

24.7

 
Table 5

Patients' knowledge about psoriasis and information need distributed in the 3 Italian areas

Item

Total responders

North

Centre

South

p

 

No

%

No

%

No

%

No

%

 

Patient's opinion of doctor's explanation of the health problem

Positive

1875

96.0

528

76.3

364

62.0

330

55.4

< 0.0001

Negative

  

59

8.5

97

16.5

114

19.1

 

Don't know

  

105

15.2

126

21.5

152

25.5

 

Patient's view of the best information source on disease treatment

Dermatologist

1870

95.7

434

63.2

333

56.7

292

49.0

< 0.0001

General practitioner

  

162

23.6

60

10.2

137

23.0

 

Patient association

  

30

4.3

132

22.5

66

11.1

 

Other

  

61

8.9

62

10.6

101

16.9

 

Patient's view as to whether patients require more information concerning therapy

Yes

1884

96.4

607

88.1

575

96.5

482

80.5

< 0.0001

No

  

82

11.9

21

3.5

117

19.5

 

Patient's opinion of the best information source on psoriasis

General practitioner

1842

94.3

148

23.0

113

19.0

121

20.0

< 0.0001

Pharmacist

  

21

3.3

6

1.0

44

7.3

 

Dermatologist

  

265

41.2

207

34.8

197

32.6

 

Illustrated medication leaflet

  

7

1.1

7

1.2

19

3.2

 

Health personnel

  

49

7.6

42

7.1

39

6.5

 

Friends and family

  

13

2.0

5

0.8

16

2.6

 

Health magazines

  

30

4.7

17

2.9

33

5.5

 

Books

  

6

0.9

1

0.2

6

1.0

 

Internet

  

25

3.9

53

8.9

42

7.0

 

Newspapers

  

7

1.1

11

1.8

11

1.8

 

Information campaigns

  

42

6.5

34

5.7

20

3.3

 

Patient associations

  

19

3.0

95

16.0

34

5.6

 

Other

  

11

1.7

4

0.6

22

3.6

 

Knowledge of patients' rights

Yes

1726

88.3

154

26.0

178

30.8

178

32.0

0.06

No

  

438

74.0

400

69.2

378

68.0

 

Knowledge of homeopathic medication and herb-based products

Yes

1855

94.9

124

19.1

123

20.6

187

30.7

< 0.0001

No

  

526

80.9

473

79.4

422

69.3

 

Knowledge of therapies such as acupuncture, the use of phototherapy

Yes

1848

94.6

159

24.5

150

25.4

195

32.0

0.005

No

  

489

75.5

441

74.6

414

68.0

 

Discussion

This study is the first one in Italy to be carried out using a questionnaire developed in close collaboration with a National Psoriasis Patient Association named A.DI.PSO. This methodological choice was based on the assumption that suggestions from the Association would correspond more closely to the actual needs of psoriatic patients. In fact, as expected, the data from this study allowed us to identify areas in Italy requiring improvement. It emerged that preventive programmes are required for risk factors such as smoking and drinking [1215], especially in central and southern Italy for smokers in the 20 – 59 age groups and for drinkers (> 2 glasses/day) in the North in the ≥ 60 age group.

The frequency of PsA in our study population was 26% which is within the range reported by other authors [35, 16]. The highest frequency of PsA was in the North (48.1%) and in men. The presence of PsA complicates disease management due to both its physical and emotional impact: PsA often makes simple every day activities difficult whilst on an emotional level can cause anxiety and depression [17]. The complexity of management of psoriasis can also be aggravated, as in our population series, by the concomitant occurrence of other diseases such as obesity in 36% of patients, type 2 DM (34%) and hypertension (32%) and depression (30%). The distribution of obesity and hypertension did not differ for geographical area or gender, whilst type 2 DM had a higher frequency in females in the South. The association of such diseases with psoriasis is often due to nutritional factors such as a high-calorie diet. In fact, improvement of psoriasis in places with an insufficient food supply (e.g. prison camps) has been reported [18, 19]. If the problem therefore lies with lifestyle, then the approach to be adopted by the public health system should focus on health education and health promotion as means of prevention.

A further aspect we investigated in this study was the quality of the assistance perceived by the patient at public dermatologic clinics on an organizational and comfort level. Although it was difficult to establish minimum standards owing to a lack of recent studies on a national level, a demand nevertheless emerged for improvements in patient reception in public services. This demand focussed on overcoming architectonic barriers and reducing time the patient spent in the waiting room especially in South Italy. It also emerged that patients in the North were more satisfied with the relationship with health staff as shown by the patient's positive impression about the confidentiality, privacy, helpfulness and courtesy of the health staff. This positive aspect was also confirmed by the fact that the general practitioner and the dermatologist in particular were considered the best source of information about their disease by the patients. Previous studies showed that a good doctor-patient relationship is the most important factor in determining patient's satisfaction [2022]. Continuous improvements in the doctor-patient relationship is an important aim as it leads to better therapeutic compliance; in fact doctors can learn to change their style of communication as other studies have previously shown [23, 24].

Interestingly, patients relied significantly on no-profit A.DI.PSO association for inquiry about their disease. Such information were indeed considered more helpful than those provided by campaigns promoted by the public health system.

Conclusion

In conclusions, the results of our study showed that there is a good basis, such as the patient-doctor relationship for initiatives aimed at improving the outcome of some of the indicators used in this study.

Declarations

Acknowledgements

The Authors would like to thank Maurizio Maravalle (Faculty of Economics of the University of L'Aquila) for the advises on the statistical interpretation of results and the following dermatologists for their participation in the study:

Gianfranco Altomare (Milano)

Fabio Arcangeli (Cesena)

Mario Aricò (Palermo)

Giuseppe Arzenziano (Napoli)

Pier Giacomo Calzavara Pinton (Brescia)

Ugo Bottoni (Catanzaro)

Giuliano Brandozzi (Ascoli Piceno)

Francesco Cusano (Benevento)

Santo Dattola (Reggio Calabria)

Antonia Galluccio (Benevento)

Giampiero Girolomoni (Verona)

Giovanni Lo Scocco (Prato)

Torello Lotti (Firenze)

Patrizia Martini (Lucca)

Giuseppe Micali (Catania)

Iria Neri (Bologna)

Andrea Peserico (Padova)

Pietro Santoianni (Napoli)

Gino Antonio Vena (Bari)

Authors’ Affiliations

(1)
Department of Internal Medicine and Public Health, University of L'Aquila
(2)
Italian Association of Psoriatic Patients (ADIPSO)
(3)
Department of Dermatology, University of Modena and Reggio Emilia
(4)
Department of Dermatology, University of L'Aquila
(5)
Department of Dermatology, University of Rome Tor Vergata

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  25. Pre-publication history

    1. The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/7/59/prepub

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© Altobelli et al; licensee BioMed Central Ltd. 2007

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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