LAUSR

skin itching, flaking or pain, and embarrassment about appearance, were rated as having the highest impact (average of 3 9 1 14 and 3 3 1 53 out of 5, respectively). However, in contrast to the article of Simpson et al., we found that encouragement from family and friends and concern about other related health effects had less bearing (average of 2 6 1 47 and 2 7 1 47 out of 5, respectively). The authors also addressed patient feelings of discouragement regarding secondary-care referral and treatment options. We found a similar trend towards feelings of discouragement from seeking additional care, particularly in those with higher pretreatment severity. Lastly, the authors alluded to greater treatment satisfaction among patients who had received secondary-care referral. Our study also confirmed the importance of referral to dermatology. We compared patients treated by dermatologists vs. nondermatologists and found that dermatologist-treated patients reported greater disease improvement (50% vs. 13%, P = 0 047), greater treatment satisfaction (80% vs. 50%, P = 0 06) and feeling more informed of treatment options (89% vs. 57%, P = 0 03). Additionally, no patient treated with a biological or systemic medication received psoriasis treatment from a primary-care provider (PCP), and this trend was also found in a previous survey of PCPs, where none reported prescribing systemic therapy. Taken together, these studies give insight into why patients with psoriasis remain undertreated despite significant advances in therapies. Continued investigation into treatment barriers and interventions that actively inform and engage patients in their disease management is needed.