Dermatology: Practical and Conceptual Original Article | Dermatol Pract Concept. 2025;15(1):4831 1 Assessing Psychosocial Burden in Psoriasis Patients Using the PRISM-RII Tool: A Comprehensive Evaluation Elif Afacan Yıldırım1, Muhterem Polat2, Yusuf Ezel Yıldırım3 1 Demiroglu Bilim University Faculty of Medicine, Department of Dermatology, Istanbul, Turkey 2 Gazi University Faculty of Medicine, Department of Dermatology, Ankara, Turkey 3 Department of Psychiatry, University of Health Sciences, Medicine Faculty, Bakirkoy Prof. Dr. Mazhar Osman Training and Research Hospital for Psychiatric, Neurological and Neurosurgical Diseases, Istanbul, Turkey Key words: Psoriasis, Psychodermatology, Psychological Impact Citation: Afacan Yıldırım E, Polat M, Yıldırım YE. Assessing Psychosocial Burden in Psoriasis Patients Using the PRISM-RII Tool: A Comprehensive Evaluation. Dermatol Pract Concept. 2025;15(1):4831. DOI: https://doi.org/10.5826/dpc.1501a4831 Accepted: October 9, 2024; Published: January 2025 Copyright: ©2024 Afacan Yıldırım 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: None. Competing Interests: None. Authorship: All authors have contributed significantly to this publication. Corresponding Author: Afacan Yıldırım E, Demiroglu Bilim University Faculty of Medicine, Department of Dermatology, Istanbul, Turkey. E-mail: eliff_afacan@hotmail.com Introduction: Psoriasis is a chronic, immune-mediated inflammatory disease that significantly impacts patients’ quality of life due to its visible lesions and associated stigma. Psychological comor- bidities are prevalent among psoriasis patients. Objectives: This study aimed to evaluate the utility of the Pictorial Representation of Illness and Self Measure Revised II (PRISM-RII) tool in assessing the psychosocial burden, including internalized stigma, in psoriasis patients. Methods: A cross-sectional study was conducted with 190 psoriasis patients recruited from a university hospital dermatology treatment center. Participants completed the PRISM-RII Psoriasis Internalized Stigma Scale (PISS), Hospital Anxiety and Depression Scale (HADS), and Dermatology Life Quality Index (DLQI). Clinical severity was measured using the Psoriasis Area and Severity Index (PASI). Results: Significant correlations were observed between PRISM-RII parameters and measures of qual- ity of life, internalized stigma, anxiety, and depression. Our study revealed significant differences in PASI scores among different Illness Perception Measures (IPM). A negative correlation was found between PASI and Self-Illness Separation (SIS), suggesting that increased disease severity is associated with a higher perceived burden of illness. Additionally, significant negative correlations were observed between SIS and DLQI, HADS, and PISS. Patients with larger IPM reported higher levels of anxiety, depression, and internalized stigma, as well as lower treatment satisfaction. ABSTRACT 2 Original Article | Dermatol Pract Concept. 2025;15(1):4831 Introduction Psoriasis is a prevalent and chronic immune-mediated in- flammatory disease that profoundly impacts patients’ qual- ity of life [1]. Characterized by the presence of erythematous, scaly plaques, psoriasis not only imposes a physical burden but also significantly affects psychological well-being. The chronic nature of the disease, coupled with the visibility of lesions, contributes to the high psychosocial morbidity [2]. Stigmatization is a major concern for patients with psoria- sis, stemming from the visibility of their skin lesions. This stigmatization can lead to social isolation, diminished self- esteem, and a deteriorated quality of life.1 Recently, the focus has expanded to internalized stigma, where patients internal- ize societal prejudices and develop negative self-perceptions [3-4]. Internalized stigma exacerbates the psychological bur- den, manifesting as feelings of worthlessness, shame, and so- cial withdrawal [5]. A multicenter cross-sectional study has shown that internalized stigma in psoriasis patients is linked to increased disease severity, involvement of visible body parts, poorer quality of life, negative perceptions of general health, and various psychological disorders [4]. Additionally, psoriasis patients are susceptible to psychiatric conditions such as anxiety, depression, bipolar disorder, cognitive im- pairment, addictions, and suicidal ideation [2, 6-9]. To accurately assess the psychosocial burden of psoria- sis, effective measurement tools are essential. The Pictorial Representation of Illness and Self Measure (PRISM) is a val- idated graphical tool used to measure illness-related suffer- ing in various chronic conditions, including dermatological diseases [10-12]. PRISM-RII, a refined version of PRISM, includes 2 key parameters: Self-Illness Separation (SIS) and Illness Perception Measure (IPM) [13]. Through these pa- rameters, PRISM-RII provides a holistic view of the emo- tional and psychological dimensions of disease burden. Objectives To the best of our knowledge, the PRISM-RII version has not been previously utilized in patients with psoriasis. More- over, no studies to date have investigated the relationship between PRISM and internalized stigma in any patient pop- ulation. The primary aim of this study was to investigate the relationship between PRISM-RII, quality of life, internalized stigmatization and psychological conditions in psoriasis pa- tients. By evaluating the utility of the PRISM-RII tool, we aim to enhance the understanding of the psychosocial bur- den in psoriasis and support the development of more ef- fective, patient- centered care strategies. The insights gained from this study could inform future interventions aimed at reducing stigma and improving the mental health and qual- ity of life for individuals living with psoriasis. Methods Study Design and Participants In this cross-sectional study, the patients were recruited from the psoriasis treatment center at the Department of Derma- tology, Gazi University, Ankara, Turkey. Ethical approval was obtained from the Institutional Review Board (approval number: 512, date: 07.08.2020) The study was conducted in accordance with the ethical standards described in an appropriate version of the 1975 Declaration of Helsinki, as revised in 2018. Following written informed consent, we employed several validated tools to comprehensively assess the psychosocial burden of psoriasis on patients. These tools included PRISM-RII, Psoriasis Internalized Stigma Scale (PISS), Hospital Anxiety and Depression Scale (HADS), and Dermatology Life Quality Index (DLQI). In addition to the questionnaires, self-reported treatment satisfaction was measured by a single statement that patients responded on a 5-point Likert-type scale. All dermatological assessments including PASI (Psoriasis Area and Severity Index) were per- formed by qualified dermatologists. Measurement Tools Pictorial Representation of Illness and Self Measure Revised II (PRISM-RII) PRISM is a non-verbal instrument designed to measure illness- related suffering [12]. In 2008, Wouters et al [13] developed 2 modifications of the original PRISM tool: the PRISM-R1 and PRISM-RII. In the article, the authors re- ported that PRISM-RII in particular would be useful and applicable tool for assessing patients suffering [13]. The PRISM-RII consists of a large white circle (186 mm in diameter) labeled “My life environment.” Patients place a yellow circular 52-mm disc (the self-disc) in the center of this white circle, representing their life (Figure 1). Partici- pants then choose 1 of 3 differently sized red discs (the illness discs) according to the perceived size of their illness. This quantitative variable is called the Illness Perception Measure (IPM). The illness discs are smaller, equal, or larger in size Conclusions: The PRISM-RII tool effectively captures the psychosocial burden of psoriasis including internalized stigmatization, highlighting the need to address both physical and psychological aspects in clinical practice. Incorporating PRISM-RII into routine assessments can enhance patient-centered care by identifying and addressing the psychosocial dimensions of psoriasis. Original Article | Dermatol Pract Concept. 2025;15(1):4831 3 (IPM-1 = 35 mm, IPM-2 = 52 mm, and IPM-3 = 65 mm, respectively) than the self-disc. Larger illness disc indicates a greater perceived severity of the illness. Self-Illness Sepa- ration (SIS) is calculated by measuring the distance between the centers of the yellow disc and the red disc, with possible SIS values ranging from 0 to 93 mm [13]. Psoriasis Internalized Stigma Scale (PISS) The scale was adapted from the Internalized Stigma Scale (ISS) [14] to effectively measure the subjective experience of stigma in psoriasis patients [3-4]. The PISS is a 4-point Likert-type scale composed of 29 items measuring the stigma across multiple dimensions; (i) alienation (6 items); (ii) ste- reotype endorsements (7 items); (iii) perceived discrimination (5 items); (iv) social withdrawal (6 items); and (vi) stigma resistance (5 items). The total PISS scores range from 4 to 91. Hospital Anxiety and Depression Scale (HADS) HADS is a widely used tool for detecting anxiety and de- pression in patients with physical illnesses [15]. The scale includes two subscales for anxiety and depression, each com- prising seven items rated on a 4-point Likert scale. The Turk- ish validity and reliability study of the scale was performed by Aydemir et al [16]. Dermatology Life Quality Index (DLQI) The scale is a specific health-related quality of life (HRQOL) instrument consisting of 10 items that assess the impact of skin disease on various aspects of daily life using a 4-point Likert scale [17]. The Turkish version of the DLQI has been validated [18]. The total scores of DLQI range from 0 to 30. Statistical Analysis The statistical analyses were conducted using IBM SPSS Sta- tistics Version 23.0. Data normality was assessed with the Shapiro-Wilk test. Descriptive statistics were used to summa- rize demographic data and disease characteristics. Contin- uous variables were presented as mean±standard deviation (SD), while categorical variables were expressed as frequency counts and percentages. To compare the means of normally distributed continuous variables across more than two groups, one-way analysis of variance (ANOVA) was used, followed by post-hoc analyses with the Tukey HSD test. For non-parametric data across more than 2 groups, the Kruskal- Wallis test was utilized. Correlations were assessed with Spearman rank correlation coefficient for non-parametric data and Pearson correlation for parametric data. The signif- icance threshold was set at P < 0.05. Results Study Population The study population comprised 190 psoriasis patients aged 18 years and over, recruited from the psoriasis treatment center at a university hospital. The severity of chronic plaque psoriasis was assessed using PASI, with a mean score of 4.10 (range: 0-26). The sociodemographic and clinical char- acteristics are presented in Table 1. Figure 1. Illustration of the Pictorial Representation of Illness and Self-Measure-Revised II (PRISM-RII). The patient is instructed to place the yellow disc on the board and then select 1 of the 3 red discs of varying sizes to place on the board. Table 1. Sociodemographic and Clinical Data of the Patients. Sociodemographic and Clinical Data N (%) Age, Mean±SD 44.07±14.18 Gender (female) 93 (48.9) Marital status Married 141 (74.2) Single 41 (21.6) Divorced/ widowed 8 (4.2) Educational level Primary school 42 (22.1) Secondary school 74 (38.9 Bachelor 74 (38.9) Occupation Employed 82 (43.2) Unemployed 63 (33.2) Student 16 (8.4) Retired 29 (15.3) Family history of psoriasis (yes) 68 (35.8) Type of psoriasis Chronic plaque psoriasis 160 (84.2) Palmoplantar pustular psoriasis 26 (13.7) Generalized pustular psoriasis 4 (2.1) SD = standard deviation. 4 Original Article | Dermatol Pract Concept. 2025;15(1):4831 discrimination, and social withdrawal. These results suggest that higher levels of internalized stigma are associated with a greater perceived burden of illness. Furthermore, significant correlations were noted between DLQI and HADS-Total (r = 0.388, P = 0.000), HADS-Anxiety (r = 0.400, P = 0.000), and HADS-Depression (r 0= .301, P = 0.000). Analysis of Variance in IPM Comparisons of HADS, PISS, and treatment satisfaction across the three IPM sizes were conducted using ANOVA (Table 3). ANOVAs revealed significant differences between PRISM-RII Parameters and Disease Severity A Kruskal-Wallis test revealed significant differences in PASI scores among the three different IPM sizes [χ2(2) = 18.934, P < 0.001]. Post hoc Mann-Whitney tests indicated significant differences between IPM-1 and IPM-3 (Z=4.10, P < 0.001) and IPM-2 and IPM-3 (Z=3.54, P < 0.001), but not between IPM-1 and IPM-2 (P = 0.232). These results suggest that as disease severity increases, the IPM value also increases, indi- cating a broader perceived impact of psoriasis on the patient life. A significant negative correlation was observed between PASI and SIS (Spearman rho = -0.238, P = 0.003), indicating that higher PASI scores are associated with lower SIS scores. The relationships between SIS, IPM, and PASI are presented in Figure 2. Relationship Between SIS and Psychological Measures The relationship between SIS and various psychological mea- sures including DLQI, HADS, and PISS was evaluated using Spearman rank correlation coefficient (Table 2). A signifi- cant negative correlation was found between SIS and DLQI, indicating that a lower SIS score, which reflects a higher per- ceived burden of illness, is associated with poorer quality of life. Similarly, significant negative correlations were ob- served between SIS and HADS-Anxiety, HADS-Depression, and HADS-Total, suggesting that patients who perceive their illness to be closer to themselves experience higher levels of anxiety and depression. Further analysis revealed significant negative correlations between SIS and PISS-Total, and PISS subscales of alienation, stereotype endorsements, perceived Figure 2. The relationship between Self-Illness Separation (SIS), Illness Perception Measure (IPM), and Psoriasis Area Severity Index (PASI). Table 2. Evaluation of the Relationship Between SIS and DLQI, HADS, and PISS. SIS (Self-Illness Separation) r, P DLQI R = -0.326, P < 0.001 HAD-Anxiety r= -0.191, P = 0.009 HAD-Depression r= -0.148, P = 0.043 HAD-Total r= -0.187, P = 0.010 PISS-Alienation r= -0.335, P < 0.001 PISS- Stereotype endorsements r= -0.264, P < 0.001 PISS- Perceived discrimination r= -0.221, P = 0.002 PISS- Social withdrawal r= -0.313, P <0.001 PISS- Stigma resistance r= -0.038, P = 0.603 PISS-Total r= -0.319, P < 0.001 DLQI = Dermatology Quality Life Index; HAD Hospital Anxiety Depression; PISS = Psoriasis Internalized Stigmatization Scale. Original Article | Dermatol Pract Concept. 2025;15(1):4831 5 Conclusions The present study demonstrates the role of PRISM-RII in highlighting the significant impact of quality of life, inter- nalized stigma, and psychological comorbidities such as de- pression and anxiety, on patients with psoriasis. Our findings align with existing literature, emphasizing the importance of addressing both the physical and mental health aspects of psoriasis [1,2,7,13,19]. This discussion explores the com- plex interplay between psoriasis severity, psychological co- morbidities, internalized stigmatization and patient quality of life. Patient perception of the disease impact often diverges from objective disease parameters that assess the extent, thickness, and erythema of lesions in skin disorders [20]. Consequently, scales such as DLQI, Skindex-29, and HRQOL have been developed to evaluate patients’ quality of life. Patient- reported outcomes such as quality of life question- naires and other psychometric assessments measuring stig- matization and psychological comorbidities provide valuable insights into the disease burden in psoriasis patients. How- ever, these questionnaires and scales have certain limitations. Firstly, they can be perceived as time-consuming and cumber- some, a phenomenon known as ‘respondent burden’ may be caused due to the repeated assessments and this also affects the willingness of the patient to complete the scales [11]. Moreover, while written qualitative questionnaires may be valid in the cultural region where they were developed, they may not yield equally meaningful results when applied to the size of IPM and HADS-Anxiety, HADS-Depression, and HADS-Total. Post-hoc analyses indicated that patients with larger IPM sizes, indicating greater perceived illness severity, had significantly higher anxiety and depression scores com- pared to those with smaller IPM sizes. IPM and Internalized Stigma Significant differences were noted between IPM sizes for PISS subscales: alienation, stereotype endorsements, per- ceived discrimination, and social withdrawal. Patients with larger IPM sizes reported higher levels of internalized stigma across all subscales except stigma resistance. Treatment Satisfaction There were also significant differences in treatment satis- faction, with patients perceiving their illness as more severe reporting lower satisfaction with treatment. There were no significant differences in PRISM-RII index parameters (SIS and IPM) among the subgroups of patients receiving top- ical therapy, conventional systemic drugs, or biological drugs. Summary of Findings Overall, our results indicate that the PRISM-RII effectively captures the psychosocial burden of psoriasis. Significant correlations between PRISM-RII parameters (SIS and IPM) and measures of quality of life, internalized stigma, anxiety, and depression underscore the importance of addressing both physical and psychological aspects of psoriasis in clin- ical practice. Table 3. Comparison of IPM With HAD, PISS, and Treatment Satisfaction Using One-Way Analysis of Variance (ANOVA). IPM-1 Mean ± SD IPM-2 Mean ± SD IPM-3 Mean ± SD F P P1 P2 P3 HAD-Anxiety 6.17±4.32 7.62±4.17 9.42±4.11 7.77 0.001 0.098 <0.001 0.069 HAD-Depression 4.72±2.96 6.65±3.99 7.57±4.22 8.83 <0.001 0.006 <0.001 0.402 HAD-Total 10.89±6.73 14.28±7.36 17.00±7.60 9.81 <0.001 0.014 <0.001 0.122 PISS-Alienation 10.19±3.32 12.89±3.79 15.07±4.59 21.99 <0.001 <0.001 <0.001 0.010 PISS- Stereotype endorsements 10.86±3.14 12.74±3.31 13.70±2.80 11.90 <0.001 0.001 <0.001 0.254 PISS- Perceived discrimination 7.75±2.33 9.35±2.80 10.14±2.94 11.84 <0.001 0.001 <0.001 0.281 PISS- Social withdrawal 9.58±3.50 11.88±3.88 13.58±4.27 14.80 <0.001 0.001 <0.001 0.059 PISS- Stigma resistance 14.66±3.10 13.83±2.45 13.90±2.25 1.97 0.142 0.151 0.324 0.990 PISS-Total 23.85±11.84 33.21±12.09 38.75±13.22 21.02 <0.001 <0.001 <0.001 0.053 Treatment satisfaction 3.91±1.26 3.70±1.21 3.11±1.45 4.30 0.015 0.607 0.011 0.076 P1: IPM1 vs IPM2, P2: IPM1 vs IPM3, P3: IPM2 vs IPM3. F: One-way analysis of variance (ANOVA), post-hoc analyses were performed using the Tukey HSD test. IPM = Illness Perception Measure; HAD = Hospital Anxiety Depression; PISS = Psoriasis Internalized Stigmatization Scale; SD = standard deviation. 6 Original Article | Dermatol Pract Concept. 2025;15(1):4831 explored in our study. The findings revealed significant associations between disease severity and these PRISM- RII measures, aligning with prior research conducted by Fotiou et al [19], which also indicated a relationship between PRISM scores and disease severity in psoriasis. Fotiou et al [19] research further supports our findings, demonstrating that PRISM scores are influenced by the psychological dis- tress attributable to psoriasis severity. They observed that higher disease severity correlated with lower SIS scores, in- dicating a higher perceived disease burden. This aligns with our results, which showed significant negative correlations between PASI scores and SIS, suggesting that as psoriasis se- verity increases, the perceived burden of illness intensifies. However, in a study by Reimus et al [28] involving 59 psori- asis patients using PRISM-R, no significant correlation was found between PASI and PRISM-R (P = 0.14). This discrep- ancy may be attributed to differences in study populations or methodologies. In the same study, while no relationship was found between SIS and subjective health measures, a negative correlation was found between IPM and subjec- tive health status, life satisfaction, and psychological well- being. In line with this, in our study, significant correlations were observed between the size of IPM and HADS-Anxiety, HADS-Depression, HADS-Total and self-reported treatment satisfaction. The present study also found significant correlations be- tween IPM and various psychological measures, including the HADS scores and self-reported treatment satisfaction. This highlights the role of perceived illness severity in af- fecting patients’ mental health and their satisfaction with treatment outcomes. Depression is a well-documented comorbidity in psoriasis, significantly affecting patients well-being [30]. Higher PASI scores have been correlated with increased depression symptoms. Studies indicate that depression in psoriasis patients may result from several fac- tors, including the visibility of lesions, stigmatization, and the chronic nature of the disease [7,9]. Anxiety is another prevalent issue among psoriasis patients, often triggered by the chronic nature of the disease and its visible symp- toms. Studies show a bidirectional relationship where anx- iety can both result from and exacerbate psoriasis [9,31]. Our study found significant correlations between PRISM- RII parameters and measures of anxiety and depression. A lower SIS score, indicating a higher perceived burden, was significantly associated with higher anxiety and depression scores. This finding aligns with previous research suggesting that the closer patients perceive their illness to themselves, the higher the psychological burden [19]. Larger IPM, re- flecting greater perceived illness severity, were also cor- related with higher scores on the HADS. This suggests that patients who perceive their illness as more severe are more likely to experience anxiety and depression [13]. Our results patients from regions with different cultural backgrounds [11,21]. Hence, the PRISM scale emerges as an alternative and practical tool to written questionnaires. In a study by Büchi et al [10] the PRISM was prelimi- narily validated as an effective method to assess suffering in patients with chronic illnesses. This tool has since been val- idated in various chronic conditions, including, rheumatoid arthritis[12,22], chronic obstructive pulmonary disease [23], systemic lupus erythematosus [24], diabetes mellitus [10], chronic pain [25] and skin diseases [11,26-28] including mainly psoriasis [19]. This validation supports the use of PRISM-RII in our study, reinforcing its relevance in mea- suring the psychosocial burden in psoriasis patients. In our study, there was a statistically significant relationship be- tween PRISM-RII SIS scores and DLQI, similar to findings by Mühleisen et al [11], which linked PRISM-SIS scores to quality of life measures like Skindex-29 and DLQI in a study involving 186 patients. In the same study, including differ- ent patient groups such as psoriasis, dermatitis, leg ulcers, and tumors, the highest correlation between PRISM-SIS and DLQI was observed in patients with psoriasis and those with tumors [11]. Additionally, a study by Fotiou et al [19] vali- dating an earlier version of PRISM with DLQI in psoriasis patients found a correlation between SIS and DLQI. These findings are consistent with our results, where significant associations were observed between PRISM-RII scores and DLQI, highlighting the tool ability to capture the multifac- eted impact of psoriasis. Our results indicate that the SIS subscale of PRISM- RII is an effective method for evaluating quality of life in dermatology. The DLQI is one of the most commonly used dermatology-specific HRQOL instrument [21]. However, while DLQI focuses more on functional impairment, PRISM- RII captures the emotional and psychological dimensions of disease burden, providing a more holistic view of the patient experience. The PRISM-RII offers several advantages over traditional patient-reported outcome measures, such as the DLQI. PRISM-RII graphical and non-verbal nature makes it less susceptible to cultural biases and easier for patients to complete, compared to traditional questionnaires [13]. This is particularly beneficial in dermatology, where visible symp- toms can lead to varying degrees of psychological distress across different cultural contexts Corazza et al [29] high- lighted the sensitivity of PRISM in detecting the emotional impact of eczematous diseases, especially in cases involving the face. Their study found that PRISM was more accurate than DLQI in measuring the burden of diseases that have significant visible symptoms. This is particularly relevant for psoriasis patients, in which visible lesions can contribute to increased psychological distress and perceived stigma. The relationship between disease severity and PRISM- RII parameters, specifically SIS and IPM, was thoroughly Original Article | Dermatol Pract Concept. 2025;15(1):4831 7 parameters. Secondly, the study sample was recruited from a single treatment center, which may limit the generalizability of the findings. Thirdly, the reliance on self-reported mea- sures may introduce bias due to social desirability or recall inaccuracies. References 1. Zhang H, Yang Z, Tang K, Sun Q, Jin H. Stigmatization in patients with psoriasis: a mini review. Front Immunol. 2021;12:715839. DOI: 10.3389/fimmu.2021.715839. PMID: 34867945. PMCID: PMC8634029. 2. Ferreira BIRC, Da Costa Abreu JLP, Dos Reis JPG, Da Costa Figueiredo AM. Psoriasis and associated psychiatric disorders: a systematic review on etiopathogenesis and clinical correlation. J Clin Aesthet Dermatol. 2016;9(6):36-41. PMID: 27386050; PMCID: PMC4928455. 3. Alpsoy E, Babadag K, Karaman BF. Reliability and validity of in- ternalized stigmatization scale in psoriasis. Turkderm-Arch of the Turkish Dermatol and Venerol 2015;49(1):45-9. DOI: 10.4274 /turkderm.54521 4. Alpsoy E, Polat M, Fettahlıoglu-Karaman B, et al. 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Graphic repre- sentation of illness: a novel method of measuring patients’ underscore the importance of using comprehensive tools like PRISM-RII to capture the multifaceted impact of psoriasis on patients lives. Our study also examined psoriasis-related internalized stigma, elucidating the relationship between the size of IPM and PISS-Total, along with its subscales. Our study found significant negative correlations between SIS and PISS. Our findings demonstrate that higher PISS scores are significantly correlated with lower scores on the PRISM-RII SIS subscale, indicating that patients who perceive a greater distance be- tween themselves and their illness experience less internalized stigma and associated psychological distress. Patients with higher levels of internalized stigma reported poorer quality of life. This finding aligns with the literature, which indicates that internalized stigma is associated with a lower quality of life and increased psychological comorbidities in psoriasis patients [4]. Our study highlights the significant role of in- ternalized stigma in psoriasis patients and its impact on psy- chological well-being, as measured by the PRISM-RII. The results of the present study reveal that the PRISM-RII is a practical instrument that can be used to measure internalized stigma in psoriasis patients. The integration of PRISM-RII into clinical practice can help healthcare providers identify patients with internalized stigma, enabling targeted interven- tions aimed at reducing stigma and improving psychological well-being. Addressing internalized stigma is crucial for en- hancing the overall treatment and management of psoriasis. The PRISM-RII stands out as an exceptional measure for assessing the psychosocial burden in psoriasis patients. It ef- fectively captures the intricate interplay between disease se- verity, perceived illness burden, quality of life, psychological comorbidities and internalized stigma, offering invaluable insights that can enhance patient-centered care strategies. One of the key advantages of the PRISM is that it is an easy- to-apply and practical graphical tool, making it less suscep- tible to cultural differences compared to traditional written questionnaires. By integrating tools like PRISM-RII into rou- tine clinical assessments, healthcare providers can compre- hensively address the psychosocial dimensions of psoriasis, paving the way for more holistic and effective patient care. Future research should consider longitudinal studies to ob- serve changes in the psychosocial burden of psoriasis over time and the long-term effectiveness of interventions target- ing internalized stigma, anxiety, and depression. 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