Dermatology: Practical and Conceptual Original Article | Dermatol Pract Concept. 2025;15(2):4644 1 Psoriasis and Emotional Dysregulation: A Multicenter Analysis of Psychodermatology Outcomes Tonia Samela*1,3, Gaia Moretta2, Alessia Provini2, Gianluca Pagnanelli2, Claudio Bonifati4, Dario Graceffa4, Viviana Lora4, Diego Orsini4, Arianna Zangrilli5, Domenico Giordano6, Annunziata Dattola7, Antonio Richetta7, Nicoletta Bernardini8, Giacomo Caldarola9, Eleonora De Luca9, Cinzia Masini10, Mauro Bavetta10, Paola Tribuzi11, Vincenzo Panasiti12, Damiano Abeni3 1 Clinical Psychology Unit, Istituto Dermopatico dell’Immacolata, IDI-IRCSS, 00167, Rome, Italy 2 Dermatology Unit, Istituto Dermopatico dell’Immacolata, IDI-IRCSS, 00167, Rome, Italy 3 Clinical Epidemiology Unit, Istituto Dermopatico dell’Immacolata, IDI-IRCSS, 00167, Rome, Italy 4 Department of Clinical Dermatology, San Gallicano Dermatological Institute, IRCCS, Rome, Italy 5 Department of Dermatology, University of Rome Tor Vergata, Rome, Italy 6 NESMOS Department, Dermatology Unit, Sant’Andrea Hospital, University of Rome Sapienza, Rome, Italy 7 Unit of Dermatology, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy 8 Dermatology Unit “Daniele Innocenzi,” ASL Latina, Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Italy 9 Dipartimento di Scienze Mediche e Chirurgiche, UOC di Dermatologia, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy 10 UOC Dermatologia, Ospedale San Sebastiano, Frascati (RM), Italy 11 UOC Dermatologia, Ospedale Belcolle, Viterbo, Italy 12 Unit of Plastic and Reconstructive Surgery, Campus Bio-Medico University, Rome, Italy Key words: Psycho-dermatology, Psoriasis, Emotional dysregulation, Multicenter Study, Mental Health Citation: Samela T, Moretta G, Provini A, et al. Psoriasis and Emotional Dysregulation: A Multicenter Analysis of Psychodermatology Outcomes. Dermatol Pract Concept. 2025;15(2):4644. DOI: https://doi.org/10.5826/dpc.1502a4644 Accepted: December 27, 2024; Published: April 2025 Copyright: ©2025 Samela et al. This is an open-access article distributed under the terms of the Creative Commons Attribution- NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: This study was supported by the “Progetto Ricerca Corrente” of the Italian Ministry of Health, Rome, Italy. Competing Interests: None. Authorship: All authors have contributed significantly to this publication. Corresponding Author: Tonia Samela, Clinical Psychology Unit, Clinical Epidemiology Unit, IDI-IRCCS, Via dei Monti di Creta, 104, 00167 Rome, Italy. E-mail: t.samela@idi.it Introduction: Psychological symptoms associated with psoriasis include depression, anxiety, and so- cial phobia, often exacerbated by high rates of alexithymia. Treatment decisions should consider not only clinical severity but also patient characteristics and quality of life. However, the psychosocial burden of psoriasis may not always align with clinical severity. ABSTRACT 2 Original Article | Dermatol Pract Concept. 2025;15(2):4644 Introduction Psoriasis is a chronic, inflammatory skin disease based on a polygenic vulnerability, with relevant cutaneous and systemic manifestations [1]. The burden of disability of psoriasis has been estimated to be equal to other major chronic diseases [2, 3]. Several studies highlight that patients with psoria- sis may experience severe psychological symptoms related to their skin condition [4]; moreover, the high prevalence of alexithymia suggests that labelling and regulating inner states and emotions may be not easy for these patients [5]. The guidelines for clinicians recommend biologi- cal therapies as second-line treatment for patients with moderate-to-severe psoriasis (Psoriasis Area Severity Index, PASI ≥ 10) [6]. In real-life experiences, patients categorized with high disease severity and low illness perception had a higher chance of receiving biological treatment compared to those with low disease activity and high illness perception. Furthermore, the perceived psychosocial burden due to psoriasis is often not consistent with the severity of the dis- ease as assessed by clinicians [8-10]; this may highlight that even patients with mild-to-moderate disease severity experi- ence relevant levels of psychological distress [11]. Various psychosocial interventions have been tested to improve dermatologic patients’ mental health, with encour- aging results [12], although more rigorous studies are still needed to assess feasibility procedures [13]. A key role for better mental health is played by emo- tional regulation skills [14, 15]. Emotional regulation is a construct that refers to the processes by which individuals appraise, label, regulate, dis- play, and experience their emotions [16]: the absence of any of these skills may indicate difficulties in emotional regula- tion [14]. Recent studies have identified a high risk of emotional dysregulation [17-21] and a low ability to process emotional information (i.e., emotional awareness) in patients with pso- riasis [19, 22]. These psychological difficulties could be risk factors for exacerbation and persistence of psychopathology as well as an obstacle to therapeutic adherence [23], to pro- viding emotional support, and to sustaining mental health in these patients. Moreover, emotional dysregulation may af- fect the patient’s illness perception, which may, in turn, con- tribute to the mismanagement of chronic diseases [24-27]. The perception of overwhelming emotional demands drains the psychological resources needed for everyday self man- agement of chronic diseases like psoriasis, contributing to poor health outcomes [28], and may lead to an increase in perceived illness severity in these patients [17]. Patients with psoriasis frequently report several psycho- logical conditions associated with the presence of difficulties in emotional regulation, independently from their disease se- verity. Thus, we hypothesized that outpatients, even those with mild-to-moderate levels of psoriasis, may have difficulties in understanding and regulating their inner states and emotions, with serious consequences to their mental health and treatment satisfaction. Consistently with this hypothesis, we aimed to de- scribe difficulties in emotion regulation in outpatients affected by plaque psoriasis, comparing these scores with normative Objectives: This study aimed to assess emotional regulation difficulties in outpatients with psoriasis, comparing these difficulties to those of the general population and examining associations with socio- demographic factors, comorbidities, and treatment options. Methods: A cross-sectional, multicenter study enrolled 107 consecutive patients with psoriasis from dermatological centers in Lazio, Italy. For every patient the Psoriasis Area Severity Index (PASI), In- vestigator’s Global Assessment (IGA), and Difficulties in Emotional Regulation scale (DERS) were recorded. Results: Analysis revealed that patients with psoriasis reported significantly higher emotional regula- tion difficulties compared to the general Italian population, even those with mild disease. A significant association was found between psoriasis severity and emotional regulation difficulties, particularly in patients with higher PASI scores. Biological treatments were associated with lower levels of emotional regulation difficulties. Conclusions: This study corroborates the existing literature on the association between psoriasis severity and emotional regulation difficulties. However, it diverges from prior findings regarding the association between body mass index (BMI) and emotional dysregulation. Assessing emotional regu- lation difficulties may aid clinicians in identifying vulnerable patients and optimizing treatment deci- sions to improve overall quality of life and treatment adherence. Further research is needed to validate these findings and to explore longitudinal associations between emotional regulation and psoriasis outcomes. Original Article | Dermatol Pract Concept. 2025;15(2):4644 3 values provided in the Italian adaptation of the Difficulties in Emotional Regulation Scale (DERS) derived from the general Italian population, and to detail these difficulties in terms of sociodemographic features and treatment options. Materials and Methods Study Design, Setting, and Participants This work was a cross-sectional multicenter descriptive study approved by the Ethics Committee of the IDI-IRCCS (protocol number: 682/1). From October 2022 to April 2023, we recruited 107 consecutives patients with a diag- nosis of psoriasis, admitted in 10 dermatological centers in Lazio, Italy. In order to participate in the study, the inclusion criteria were: 1) age ≥18 years, both sexes; 2) having a diag- nosis of plaque psoriasis; 3) requiring pharmacological inter- vention (i.e., topical or systemic); 4) PASI ≠ 0; 5) to be able to understand the Italian language and to have signed the informed consent and accepted to participate in the study. The exclusion criteria were: 1) suffering from a diagnosed psychopathology; 2) having undergone psychopharmacolog- ical treatment or psychotherapy in the previous year. Measures In this study the extent and severity of psoriasis were evalu- ated by PASI; the other tool used to assess psoriasis severity was the 6-point Investigator Global Assessment (IGA) [29]. Sociodemographic and clinical features were collected and analyzed as means and standard deviation for continuous variables and as frequencies and percentages for categorical variables. Difficulties in emotional regulation were assessed by the Difficulties in Emotional Regulation scale (DERS) [30] in its Italian adaptation provided by Sighinolfi et al. [31]; this self-report questionnaire [32] makes it possible to obtain measurements regarding the presence of potential difficul- ties in the following dimensions: (1) Nonacceptance (non- acceptance of emotional responses); (2) Goals (difficulty in adopting goal-oriented behaviors); (3) Impulse (difficulty in controlling impulses); (4) Awareness (lack of emotional awareness); (5) Strategies (limited access to emotional regu- lation strategies); (6) Clarity (lack of emotional clarity). Data Collection Procedures and Statistical Analysis The study sample corresponds to the actual number of outpa- tients seen during the study period who agreed to participate in the study; no sample size calculation was performed. So- ciodemographic information was summarized in frequency distributions, and the patient-reported outcomes as means and standard deviation. Cronbach’s alpha was calculated to evaluate the reliability and internal consistency of DERS subscales in this sample. All sociodemographic and clinical variables were used as independent variables in the multi- ple linear regression models, with DERS subscale scores as the criterion. The associations were reported as standardized beta coefficients (β) and their p-values. All analyses were per- formed using the Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, Version 28.0.1.0). Results Our sample included 107 patients (55.2% women), aged from 18 to 81 years (Table 1). The Cronbach’s alpha for the subscales of the DERS in the current sample were as follows: Nonacceptance of emotional responses: α= 0.76; Goals: α= 0.77; Impulse: α= 0.63; Awareness: α= 0.72; Strategies: α= 0.87; Clarity: α= 0.67, DERS Total score: α= 0.95. No significant difference was found in difficulties in emotional dysregulation for sex, age, BMI, biological treatment, or comorbidity, whilst participants with mild-to-severe PASI had higher scores in the Goals and Impulse DERS subscales (Goals P<0.02; Impulse P<0.03). Also, a higher level of dis- ease severity measured by IGA and lower level of educa- tional attainment (<13 years) were found to be associated with higher scores in DERS Acceptance subscale (P<0.04 and P<0.01, respectively). Comparing DERS subscale scores obtained by people recruited in our sample with the nor- mative values provided by Sighinolfi et al. [31] for the Ital- ian adaptation of the tool, except for the “Goals” subscale, all mean differences for each subscale were found to be statistically significant, with higher scores recorded in our patient sample (Table 2). Linear regression analyses were performed to investigate whether sociodemographics and clinical variables were significant predictors of DERS mean scores. Each DERS subscale score was tested as dependent variable, with sex, age, BMI, PASI, education level, biolog- ical treatment, and numbers of comorbidities as indepen- dent variables (Table 3). No sociodemographics or clinical variable was found to be significantly associated with DERS “Awareness” subscale. BMI was negatively associated with “Goal” subscales (P=0.006). PASI scores were found to be positively associated with “Acceptance” and “Goal” mean scores (P=0.007 and P=0.026, respectively). Education level was found to be negatively associated with “Acceptance” mean scores (P=0.026). Biological treatments were found to be negatively associated with “Goal” mean scores and with “Strategy” means scores (P=0.02 and P=0.04, respectively). Finally, comorbidities were found to be positively associated with “Goal” and “Strategy” subscales (P=0.004). Discussion The first aim of the present work consisted in detailing the difficulties in emotional regulation, as measured by DERS, 4 Original Article | Dermatol Pract Concept. 2025;15(2):4644 T ab le 1 . S oc io de m og ra ph ic a nd c lin ic al f ea tu re s of t he s am pl e, w it h D E R S su bs ca le m ea n sc or es ( N =1 07 ). V ar ia bl e L ev el s N * % A w ar en es s A cc ep ta nc e G oa l Im pu ls e St ra te gy C la ri ty O ve ra ll 10 7 6. 7 13 .7 12 .3 12 .3 18 .7 11 .2 Se x M al e 47 44 .8 6. 7 13 .8 12 .2 12 .7 18 .9 11 .0 Fe m al e 58 55 .2 6. 7 13 .7 12 .3 12 .0 18 .5 11 .4 A ge ( ye ar s) <4 0 37 34 .9 6. 5 13 .1 12 .8 12 .0 18 .9 11 .2 40 -5 9 44 41 .5 7. 0 14 .0 12 .2 12 .3 17 .9 10 .9 60 + 25 23 .6 6. 5 14 .5 11 .9 12 .8 19 .6 11 .7 B M I <2 5 50 50 .0 6. 6 14 .4 12 .8 12 .8 19 .2 11 .1 25 -2 9 34 34 .0 6. 6 13 .8 12 .0 12 .5 18 .4 11 .7 30 + 16 16 .0 7. 2 12 .2 10 .5 11 .2 18 .3 11 .0 PA SI <6 41 43 .2 6. 5 12 .3 10 .7 10 .9 17 .6 10 .7 6 to 9 19 20 .0 5. 9 14 .3 13 .5 13 .8 19 .8 11 .2 10 + 35 36 .8 7. 5 15 .4 13 .7 13 .9 20 .5 12 .0 P -v al ue 0. 01 7 0. 03 2 IG A <3 52 58 .4 6. 4 13 .0 11 .9 12 .2 18 .8 11 .2 3+ 37 41 .6 7. 3 15 .7 13 .8 13 .8 20 .4 11 .8 P -v al ue 0. 03 6 E du ca ti on