Re. major life‐changing decisions and cumulative life course impairment

Editor We wish to thank Drs. Bhatti, Salek and Finlay for their comments, and also to recognize their substantial contributions to the field. We absolutely agree with their supposition that major life-changing decisions (MLCDs) can be substantially affected by skin disease and may add to the cumulative impairment of disease. We have three additional observations to make regarding the importance of MLCDs: First, many of these decisions, such as marriage, career choice, education and child bearing, occur relatively early in most people’s lives. We draw attention to the life-course models, and specifically the ‘critical period model’ proposed by Kuh and Ben-Shlomo.1,2 The concept of critical and sensitive periods is applicable, and we postulate that the onset of psoriasis during critical or sensitive periods (e.g. adolescence and early adulthood), when a majority of these MLCDs are made, will have a greater impact on life course than later onset of psoriasis. Given that one of the peaks of psoriasis onset occurs in the late teens, this population may be particularly vulnerable to the effects of disease on MLCDs. In contrast, patients who are affected by psoriasis later in life in their 40s and 50s are likely to be more established in their career and relationships, having made many MLCDs earlier; thus, the effects of psoriasis may be less apparent. Data showing improved quality of life in older patients with similar disease severity support this concept.3,4 Treatment plans and the risk–benefit ratio may therefore be somewhat different in this younger population, but further research is required to understand the impact of psoriasis in this group. Secondly, the effects of MLCDs may magnify each other and not simply be additive. For example, poor economic status may also affect education and social status. Lastly, we agree that these concepts are likely applicable to other chronic diseases in non-dermatological areas. We continue to develop the concept of Cumulative Life Course Impairment (CLCI) in psoriasis. Specifically, we are investigating further the concept of critical time periods to understand the relative impact of various exposures on outcomes in CLCI. We look forward to seeing how this patient-centric concept and its attendant research will evolve.