Pros and Cons of Living in the Countryside

Though city living has so many perks, a lot of people also prefer to live the humble life in the countryside. Country living has a lot of benefits despite the fact that the city seems so appealing. From the beautiful scenery to friendly people, the countryside has a lot to offer. When one lives in the city for instance, he has to deal with a lot of pollution. Country living just like city living has its fair share of consequences too. The following are the pros and cons of country living discussed in detail.

Pros

Peaceful and friendly people - When you look at crime statistics, cities are more common locations for both petty and grave crimes that threaten properties and even people's safety. If you prefer peace and safety for your family over convenience, living in the country is the better choice. People are a lot friendlier too. Neighbors in big cities don't even know each other. The same is not true in the country where neighbors even share food. For families, the countryside is the better choice than the city.

Affordable cost of living - It is true that people in the city earn big salaries. The fact is that the cost of living in cities is also very high. Rent can be a burden when one doesn't own a house. Food and gas are very expensive too. The countryside on the other hand is the best place to save as foods are cheaper, eating out is not necessary and some things are even free like fruits and vegetables as you can possibly grow them.

Healthy environment - Rural areas have the unhurried lifestyle that people embrace which is a complete opposite of what's happening in the city where everything is "fast". The air is unpolluted. Noise pollution is something nonexistent in rural areas where the only sounds are those created by animals and insects. According to a study, people in big cities have higher tendencies of getting diseases caused by air pollution than those living in the country.

Cons

Long Travel Time - One major downside to living in the countryside is the long travel time. Rural areas are located miles away from big cities. There are even unpaved roads which are major reasons why travel takes too long. The best thing to do when living in the suburbs is to have your own car for ease of travel.

Inaccessibility - Remote areas don't have fast food chains and coffee shops in every corner just like in cities. There is probably just one pub, deli and gas station in a certain suburban community. The city on the other hand has everything the people need.

Recently making the move from the city to the country, Sheryl is an advocate for sustainible living and spends a lot of time researching new ways to live off the land.

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Guide to Living Well with Menopause

Menopause is a time of significant and often unpleasant changes in a woman’s life. The majority of women (up to 85%) experience symptoms related to the dramatic hormonal changes of menopause. They usually begin in the period of menopausal transition, that is; the time leading up to the final menstrual period, and typically persist post-menopause (after the final menstrual period). They include hot flushes, sexual changes, psychological and mood changes, poor quality sleep and rapidly ageing skin.

Menopausal symptoms can significantly and negatively impact on a woman’s wellbeing and quality of life. However, there are many ways to manage menopausal symptoms including simple lifestyle and behavioural measures, as well as pharmaceutical and herbal remedies. It’s a time of significant change but it is possible to live well with menopause.

Different stages of menopause typically produce different symptoms and effects. Understanding the changes that occur at different stages can help a woman understand and cope with the changes. Menopause refers to the cessation of menstruation and the time of menopause is defined as the time of the last menstrual bleeding. However, menopausal symptoms typically affect women for a significant period of time, beginning in the menopausal transition and persisting post-menopause.

The menopausal transition or period when hormonal changes begin to cause irregular menses can be further categorised as early and late stage. The early stage is characterised by menstrual cycles which vary more than 7 days from normal length (21–35 days), while the late stage is characterised by extended periods (? 60days) between menstrual bleeding. The post-menopausal period is also divided into early (the first 5 years after final menstrual bleeding) and late (thereafter) stages.

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For more information about the changes that occur in menopause and the symptoms that may be experienced, see Menopause.

The prevalence of symptoms varies at different stages of menopause. For example, hot flushes are associated with the period of menopausal transition, while sexual difficulties increase with increasing time since menopause. Thus women often need to employ different strategies at different stages to minimise the impact of menopause, and its symptoms, on their wellbeing. However, there are some general measures which will assist women to live well with menopause, regardless of stage or symptoms. These include:

Think positively about the life changes associated with menopause. The brain is a powerful organ and negative feelings are associated with a greater likelihood of? experiencing menopausal symptoms. Try to view menopause as the start of a new phase in life, rather than a negative interruption and focus on positive aspects like the cessation of menstrual bleeding;Remember that the sexual and other changes of menopause are normal and natural, even if everything feels different. It is important for women experiencing menopause to challenge beliefs which may reduce their self-esteem, such as unrealistic expectations about body shape and beauty. Aspects of ageing such as wrinkling and weight gain are normal and natural, and being aware of and accepting this is important. Focusing on life achievements and setting realistic goals for the future is also useful for women experiencing the changes of menopause;Love your new menopausal body, despite its different shape and appearance. Remember that the changes are normal and natural and try to be positive about your body and maintain its healthfor example by: Maintaining a healthy diet including minimising alcohol and caffeine consumption;Performing at least 30 minutes of moderate intensity physical activity every day; andQuitting smoking;Set aside personal time which may be used for relaxation, pursuing new interests and roles in life. Joining a volunteer group or a hobby group may also be useful in this new phase of life;Get support from friends, family members, your intimate partner and, if necessary, health professionals;Identify and address stressors, including work and children which can create stress and make menopausal symptoms more severe. For some women it may be beneficial to identify and implement strategies to overcome issues in intimate relationships. For others, developing strategies to cope with child-related issues (e.g. leaving, or not leaving home) may be more important. If you find it challenging to address the stressors in your life, talk to a health professional to organise some additional support;Consider cultural factors which may influence menopause and you attitude to it. For example, if you live in a culture where older women are less valued due to their loss of reproductive capacity and changing appearance, this may influence you to have negative perceptions about menopause. Challenge the cultural perceptions which may influence you to think negatively about menopause.

In addition there are specific measures and treatments which may help women cope with individual symptoms of menopause.

Vasomotor symptoms of menopause, commonly referred to as hot flushes, are best described as sudden sensations of heat radiating from the chest and face, and resulting in profuse sweating which persists for 2–4 minutes. However, hot flushes can last for as little as a couple of seconds or as long as a couple of hours. Flushes may occur as often as every 5 minutes or as infrequently as once or twice a year. They are the most common menopausal symptom, affecting approximately 70% of women and typically begin in the late menopausal transition. In most women hot flushes persist for 0.5–5 years, but in a minority of women continue for up to 15 years.

While menopausal hot flushes are not life-threatening, they can be distressing and reduce a woman’s quality of life, sleep quality or social life. Experiencing hot flushes is associated with a greater risk of psychological complaints such as depressed mood and anxiety. However, there are many strategies which women can employ to ensure they continue living well when vasomotor symptoms arise.

For the majority of women (60%) who experience mild vasomotor symptoms, general measures which?improve overall health and wellbeing (discussed above) may be sufficient for living well with hot flushes. However, women may also benefit from lifestyle measures specifically aimed at reducing the occurrence of hot flushes including:

Avoiding certain foods and beverages (e.g. spicy foods) which trigger hot flushes; andMeasures to reduce body temperature (e.g. keeping the room cool).

If these measures fail and hot flushes occur, women may be able to cool off by:

Having a cold drink or shower or using a fan;Breathing deeply and trying to relax;Running cold water on their wrists;Removing clothing: Dressing in many thin layers will make this easier;At night, getting out of bed.

Treatments

When lifestyle measures alone are insufficient to assist women to live well with menopausal hot flushes, a range of pharmaceuticals and herbal products may be of value. Hormone replacement therapy (HRT) is an effective treatment and relief of vasomotor symptoms is the primary reason women use the therapy. However, before using HRT it is important to obtain evidence-based information from a doctor about the risks and benefits of HRT, including the likelihood that vasomotor symptoms will return when the treatment is stopped

Due to the significant health risks associated with HRT (e.g. an increased risk of breast cancer), many women avoid it and opt for herbal remedies, for which rigorous evidence of effectiveness and safety is limited. It is important to obtain evidence-based information from a doctor regarding the effectiveness and safety of any herbal remedy before using it. Remember that natural does not necessarily mean safe.

Amongst the herbal products available, there is increasing interesting in isoflavone phytoestrogens; plant compounds with oestrogenic properties. Phytoestrogens derived from soy and red clover have been assessed for their effect on vasomotor symptoms. While some trials have reported positive results, others have reported that taking phytoestrogens did not affect the frequency or severity of hot flushes. Current evidence is considered insufficient to enable conclusions to be drawn regarding whether or not phytoestrogens effectively relieve hot flushes. There is also limited evidence for other natural therapies such as acupuncture and homeopathy in the treatment of menopausal hot flushes.

The hormonal changes of menopause have a profound effect on the function of genital organs and women’s sexual desire and response, all of which are regulated by the same hormones (predominately oestrogen and progesterone but also androgens and others). These hormones undergo dramatic changes during menopause. For example, levels of oestrogen which, amongst other functions, regulates the flow of blood to the vagina and vaginal lubrication during sexual stimulation decline rapidly and considerably. Unlike other menopausal symptoms which are usually temporary, sexual changes typically persist permanently following menopause. The majority of women experience changes in vaginal lubrication with menopause and these complaints increase in prevalence with increasing duration post-menopause. However, sexual symptoms may also occur in the menopausal transition or early post-menopausal period.

It is important to be cognisant that women’s sexual feelings and functions are also influence by psychological factors; some evidence suggests these are more influential than hormonal factors. Psychosocial and other symptoms associated with the menopause may also influence a woman’s sexual desire and response. For example, if hot flushes cause insomnia and irritability, this may in turn affect sexual functioning. Changes to a partner’s sexual function are also influential. For example, erectile dysfunction ?increases with age and negatively affects both a man and his partner’s sexual functioning. It is the cause of negative sexual changes in post-menopausal women in about one-third of cases. Midlife changes and stressors such as children leaving home or difficulties in her intimate relationships may also impact on a woman’s sexual function around the time of menopause.

While the majority of women experience negative sexual changes during menopause, it is important to be aware that a minority report sexual improvements. The hormonal changes of menopause do not necessarily impair a woman’s sexual function. In addition many women report that although sexual changes (e.g. increased vaginal dryness) occur, they do not impact on the quality of their sex life, and they are not necessarily related to menopause. For example a new sexual partner or new sexual techniques may underpin changes in the way sex feels or a woman’s libido.

If you are having difficulty coping with the sexual changes of menopause, as well as the biological, psychological and social factors which influence them, you should talk to your doctor. Ideally your intimate partner should also be involved in the discussion, which will not only provide the basis for better understanding the changes which occur, but can also be used to identify treatments and other strategies which might make coping with sexual changes easier. While treatments are highly effective (80–100%), only a quarter of women seek treatment for sexual symptoms, so many remain unaware of the lifestyle, pharmaceutical and herbal remedies which may relieve sexual symptoms.

HRT is one option, but the therapy is not usually used to treat sexual symptoms alone and many women avoid it due to safety concerns. In cases where sexual dysfunction is underpinned by psychosocial factors like stress or relationship problems, HRT may be ineffective if the psychosocial influences on sexual function are not addressed. Usually the doctor will recommend a woman tries other measures before they prescribe HRT. In the first instance there is a range of simple measures which can be trialled, including:

Use of vaginal lubricants;Addressing issues in the intimate relationship, including male sexual dysfunction;Practicing new sexual techniques, amongst which non-penetrative techniques like oral sex and intimacy may be of particular importance;Addressing socio-cultural factors which influence sexual function, for example social norms which portray sexual enjoyment as less acceptable for older women.

Other lifestyle and psychological measure which may increase sexual satisfaction amongst menopausal women include:

Remembering that good sex takes two. If a couple’s sex life deteriorates in the menopausal period, it is important to remember that the woman is not to blame. Both partners need to try to talk openly about sex, how it feels, any fears they have, and what has changed. Where possible both partners should discuss the sexual problems and possible strategies for addressing them with a health professional;Having sex and thinking about it. Regular sex (either alone or with a partner) increases vaginal elasticity which typically declines with menopause and may contribute to sexual problems. The brain is the centre of sexual desire and plays a critical role in sexual activity, so thinking positively about sex can also play an important role in sexual satisfaction. Erotic films or literature or sex toys may be good stimulus for some couples. If sexual intercourse doesn’t happen, try something different. Non-penetrative sex acts like oral sex, cuddling and massage, as well as intimate time together are also important components of a healthy sexual relationship;Treating comorbid menopausal symptoms such as hot flushes which impact on sexual functioning;?Treating conditions affecting their partners sexual function for example low testosterone ?(hypogonadism) and erectile dysfunction;Focusing on their own sex life and not comparing. Every woman has different sexual feelings during menopause, for example libido may increase or decrease. Women should focus on what feels right for them and their partner, not what their sex life used to be like or what their friends are doing;Avoiding sexually transmitted infections if they are at risk.

Treatments

If these measures fail to bring about sexual satisfaction, the doctor may prescribed topical oestrogen (creams, rings or other preparations for vaginal use), or systemic oestrogen therapy (HRT). Doctors sometimes also include testosterone in HRT for women with sexual complaints, as it has been shown to have positive effects on sexual functioning. Various oestrogen containing products are more or less effective in treating specific sexual complaints. For example, an oestrogen releasing ring is more effective than a tablet for reducing vaginal itching or irritation, but the tablet is more effective in reducing vaginal dryness. Women should be specific about the sexual symptoms they are experiencing, as this will help their doctor determine which oestrogen and other hormonal products will be most suitable for addressing the specific complaints. Comorbid menopausal symptoms may also influence the most appropriate form of treatment. For example, systemic HRT is also typically effective in treating vasomotor symptoms, whereas topical creams are not.

Women may be interested in using herbal remedies to cope with the sexual changes of menopause. These remedies are commonly used; however, evidence for their effectiveness in relieving sexual symptoms and safety is lacking.

The causes of psychological symptoms of menopause such as increasing anxiety, depressed mood, low self-esteem, irritability and memory problems, are not well understood. These symptoms may impact not only on menopausal patients but also upon the individuals with whom they live, work and play.

Oestrogen exerts an effect on many brain functions and it is scientifically plausible that the hormonal changes of menopause may induce psychological symptoms. However, it is likely that psychological symptoms occur, at least in part, as a result of other menopausal symptoms and also as a result of stressors which are more common in mid-life (e.g. children leaving home). Factors such as menopausal vasomotor symptoms, relationship problems, a history of depression and unhealthy lifestyle, all increase the risk that menopause will bring with it negative psychological symptoms.?

Many women experience negative psychological symptoms in menopause; however, it is important to remember that menopause is also associated with positive psychological changes. The majority of studies have reported that women exhibited improved psychological health following surgical menopause. Women approaching natural menopause often have positive expectations, for example that it will be the beginning of a new phase or offer new freedom from menses and the risk of pregnancy. Cultural factors influence the risk of psychological symptoms of menopause. For example, women who live in a culture which emphasises youthfulness and fertility as positive qualities may feel undervalued when they reach menopause, and are more likely to experience psychological symptoms.

General measures to improve overall health and wellbeing, such as having a positive outlook and healthy lifestyle, are important for those with psychological symptoms. Additional measures which may help these women live well with the psychological symptoms of menopause include:

Ensuring regular cognitive stimulation if they are having memory or concentration problems;Socialising which can increase mental function;Practicing relaxation and stress relief techniques which can help them cope when symptoms arise;Talking to friends, family, or, in cases of severe symptoms a counsellor;Treating comorbid menopausal symptoms like hot flushes which can impair sleep and impact on mood; andKeeping a mood diary which may help identify triggers and develop coping strategies.

Treatment

HRT has been shown to reduce psychological symptoms in menopausal women; however it is not clear if this occurs through a direct effect or secondary to relief of comorbid hot flushes. Despite this uncertainty, HRT should be considered by women experiencing psychological symptoms (and particularly those who also experience hot flushes) in the menopausal transition. Progesterone reduces the mood enhancing effects of oestrogen. While progesterone must be added to all oestrogen-replacement regimens to reduce cancer risk, a HRT regimen with a higher oestrogen to progesterone ratio will usually be prescribed for women with psychological symptoms. Testosterone and other androgens may also be useful additions for these women.?

There are also a number of herbal remedies, including gingko, ginseng, kava-kava and St John’s wort which have demonstrated some efficacy in reducing psychological symptoms such as anxiety and depressed mood. However, there are safety concerns regarding the use of ginseng and kava kava, and St John’s wort is less effective than other available treatments. Evidence also suggests that red clover isoflavone phytoestrogens can significantly reduce anxiety and depression in the short term.

Women with psychological illnesses such as major depression (which must be distinguished from mood disorders such as depressed mood) require treatment, even if they have never previously been diagnosed with a psychological illness. For some women menopause is a catalyst to discuss existing problems with a health professional, so it may be the time when an existing psychological illness is diagnosed for the first time.

Other symptoms associated with the menopausal period include sleeping difficulties and skin changes. Reduced oestrogen levels in menopausal women are thought to partly underpin the rapid ageing of skin many women experience in the menopausal period. Sleep difficulties including insomnia and breathing difficulties during sleep are amongst the most common complaints of menopausal women and are almost 3.5 times more likely to affect women in menopause compared to earlier in life. They may arise as a result of hormonal changes; however, menopausal vasomotor symptoms and stressful midlife changes are also thought to be implicated in sleep disturbance.

Like other menopausal symptoms, skin and sleep changes are benign but can significantly impact on women’s wellbeing and quality of life. Psychological symptoms may be exacerbated by negative feelings regarding the appearance of ageing skin. Poor quality sleep can also exacerbate menopausal mood disorders and impact on sexual functioning.

As with all menopausal symptoms, lifestyle changes and other simple measures can help women live well with menopausal skin and sleep symptoms. Healthy sleep and healthy skin are both associated with psychological complaints so emphasising the importance of a positive attitude and dealing with stressors that can impair sleep may be particularly important. Those with skin symptoms should also:

Wear broad spectrum sunscreen;Avoid harsh soaps and other products which may exacerbate dryness; andUse moisturising skin creams.

Those experiencing sleeping difficulties may benefit from:

Treating comorbid menopausal symptoms;Behavioural therapies targeted at improving sleep including sleep hygiene ?measures, ritualising sleep patterns, and, in severe cases, sleep deprivation;Practising relaxation or stress management techniques including biofeedback;Avoiding stimulation and heavy meals immediately before sleep.

Treatments

Skin

HRT is an effective treatment to reduce skin ageing as it reduces the loss of collagen, which gives skin its firmness and elasticity. It has also been shown to improve wound healing. However, due to associated health risks, HRT is not prescribed when skin changes are the only menopausal symptom. For women who are not able or do not want to use HRT, another treatment option is soy isoflavone phytoestrogen tablets or creams. One study reported that skin appearance improved with the use of phytoestrogen-containing cream. Other treatments which may be considered include creams containing vitamin A, dietary supplements, and selective oestrogen receptor modulators (medicines which affect the way the body uses oestrogen).

A range of cosmetic treatments which can change the appearance of aged skin (e.g. reduce wrinkles or sagging) are also available. Women considering cosmetic treatments should be cognisant that these procedures are not medically indicated and no physical health benefits are associated with cosmetic treatments. Cosmetic changes which result from the treatments do not necessarily result in improved body image or self-esteem, or greater satisfaction with the treated body part. It is also important to bear in mind that the skin changes of menopause are normal and natural, even though they may cause dissatisfaction.

Women who are considering cosmetic procedures have a range of options, from minimally invasive treatments with botulinum toxin A injection or soft tissue fillers, to more complex and risky procedures such as cosmetic surgery.

Sleep

If behavioural measures fail to improve sleep in menopausal women, other treatment options exist. Medicines used to treat insomnia may be of value in severe cases. Treatment of comorbid conditions (e.g. fibromyalgia) may also improve sleep. There is some evidence to support the use of phytoestrogen therapy with either soy or red clover isoflavones, however, evidence for the use of other herbal remedies for improving sleep quality is lacking. Women with severe, chronic insomnia may be referred to a sleep clinic for treatment.

Menopause is a time of significant changes which often have a negative impact on quality of life. However, it is possible to live well with menopause. A healthy body and mind are the basis of a happy, healthy menopause. Lifestyle and behavioural changes such as healthy eating, exercise and avoiding harmful substances should form the basis of any strategy to live well with menopause. Psychosocial measures such as socialising, participating in leisure activities, thinking positively about life and one’s menopausal body and seeking support when needed, also play an important role in making menopause a positive new phase of life rather than a negative event.

However, cultural and other factors mean some women are impacted more greatly by menopausal symptoms than others. For those that find behavioural therapies alone are insufficient to make living well with menopause a reality, the addition of established and emerging treatments should be considered and discussed with a doctor. Attention should be given to matching treatments to the specific symptoms experienced. Taking the time to fully understand the risks, benefits and evidence base for various therapies is a vital component of living well with menopause.?

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Living well with Psoriasis

Psoriasis is a skin condition underpinned by dysfunction of the immune system. It occurs in phases of relapse, remission (no symptoms) and exacerbation (severe symptoms). The primary symptom is papulosquamous skin rash, which is a red, scaly rash. Elbows, knees, scalp and trunk are the most commonly affected body parts; however, the disease can affect any body part. In mild cases the rash covers < 2% of the person’s body surface area. Disease is typically considered severe if it affects more than 10% of skin surface area. Up to 20% of people who have psoriasis have extensive skin rash. Joints are often also affected. The skin rash and other symptoms (e.g. those affecting the joints) which psoriasis causes are uncomfortable and may cause itching and burning sensations They also cause embarrassment which can have a serious impact on a person’s wellbeing.

For more information about psoriasis including types, treatments, videos and more, see Psoriasis.

The skin symptoms of psoriasis are more likely to improve spontaneously (without treatment) in summer, compared to other times of the year. However, the psychological effects of the condition may be worse during summer due to the need to expose more skin in warm conditions. Because skin rash is a highly visible symptom, it is difficult to hide from other people during summer. However, exposing the skin can be embarrassing and lead to stigma and discrimination.

People with psoriasis may be too embarrassed to participate in summer recreation activities which require the removal of clothing, such as swimming and other sports. In one study, a large proportion of people with psoriasis reported avoiding swimming and/or other sporting activities as a result of their condition. 64% reported that they avoided buying summer clothes such as short sleeved shirts, summer dresses and/or shorts. Wearing seasonally inappropriate clothing (e.g. long sleeves in summer) in an attempt to hide psoriatic skin rash is one measure people resort to in order to hide their condition. However, this strategy is also likely to draw unwanted attention.

Psoriasis is a common condition. Studies from different developed countries have reported that it affects between 1 and 4% of the total population. InAustraliaprevalence is estimated to be between 0.3–2.5% of the population. It is the reason for some 0.3–0.6% of doctor visits overall and 2.6% of all skin-related doctor visits.

Prevalence is low (0.55%) in patients < 10 years of age and increases with increasing age. Men and women are just as likely to have psoriasis; however, young females (< 20 years) have a higher risk of the disorder compared to young males. While it is uncommon to develop psoriasis in childhood or adolescence, those individuals who do tend to have more severe disease. They usually also have family members affected by psoriasis. The psychological effects of the disorder may be greater in patients who develop the condition later in life.

Genetic factors
Psoriasis has a strong genetic element (it runs in families). The risk of inheriting the condition is greatest in children with both parents and a sibling affected, and children with one or both parents (but no sibling) affected are also at increased risk. Age of onset is also influenced genetically, so people whose parents developed the condition early in life are also likely to develop psoriasis early in life. Studies have identified several genes which may affect the risk of a person developing psoriasis.

Race
Caucasians are more likely to experience psoriasis compared to other races. Individuals of Asian ethnicity have a lower risk than Caucasians and the condition is very rare in those of African ethnicity. The disease is also very rare in individuals of Native American descent.

Nutritional disorders
The risk of psoriasis is increased in individuals with type 2 diabetes or metabolic syndrome and those who are obese.

Stress
Emotional stress is associated with acute attacks of psoriasis. In one study 60% of people reported a stressful life event in the month prior to acute symptoms of psoriasis.

Injury
There is clear evidence that injury is a risk factor for the development of psoriasis.?

Location
Psoriasis is less common in regions characterised by warm sunny weather conditions.?

Biological factors
Biological factors (factors relating to the person’s body), including infection and medication use, also play a role in the development of psoriasis.

Infection
Individuals infected with HIV and those with chronic streptococcal infection have an increased risk of developing psoriasis. Those who already have psoriasis when they are infected with HIV or streptococci are likely to experience worsening psoriasis.

Medications use
Using some medications can trigger the symptoms of psoriasis to worsen. Medicines known to have this effect include:

Smoking
Smoking is an important modifiable risk behaviour for psoriasis. In one study smokers were 1.3 times more likely to develop psoriasis compared to non-smokers.

Alcohol
Alcohol consumption has affects on most body systems and organs, including the skin. Psoriasis has also been associated with alcohol consumption in some studies, although others have found no association.

Psoriasis is commonly comorbid with other diseases (the person has psoriasis and these conditions are the same time). These include:

Epidemiological evidence shows that the risk of some conditions (diabetes and obesity) increases with increasing psoriasis severity.

How quality of life is affected
Psoriasis skin rash is typically itchy and changes the appearance of skin causing redness and scaling. Psoriatic rash is physically uncomfortable, but also associated with a range of psychological problems. It is often misinterpreted by others to be a symptom of a contagious skin disorder or other condition. For example 57% of people with psoriasis report others believe their condition to be contagious, and 9% that their psoriasis rash was mistakenly interpreted to be a symptom of acquired immune deficiency syndrome (AIDS). Psychosocial problems are particularly likely and more severe in people with affected skin on the face, hands or other commonly exposed body areas. They may also be worse in summer, when warm conditions lead to many people exposing greater amounts of skin. People with psoriasis may resort to wearing clothing which is inappropriate for hot weather to hide their rash.

Impact on quality of life
The quality of life impact of psoriasis is often significant and people aged < 55 years are most likely to experience negative quality of life effects. The majority of people affected by the condition (79%) report that the condition negatively affects their quality of life. It may affect social, intimate and work relationships, daily living and self perception. Women are more greatly affected in terms of quality of life compared to men.

Relationships
Psoriasis is reported to affect people’s relationships with family members, friends and intimate partners. Those affected by the condition report feeling physically and sexually unattractive. Sexual activity is also often affected, particularly amongst those ? 54 years, amongst whom 27% report the condition negatively affects their sex life. People with psoriasis may also have difficulty interacting with family or friends and difficulty maintaining friendships. Some 7% of those affected report that they have been excluded from public facilities such as swimming pools, gymnasiums and hair dressing salons and 40% report difficulty getting equal service or treatment at these facilities. This may also affect their ability to maintain social relationships. In one study, 11% of people with psoriasis reported not wanting to have children for fear that they would inherit the condition.

Work
Psoriasis is associated with difficulties finding employment and 6% of workers with psoriasis report experiencing discrimination at work. Those who had a job reported that the condition negatively affected their ability to interact with colleagues and was the cause of an average of 2.3 days off work each year. Absenteeism from work was reported to be the source of some 40% of the total costs associated with the disease (US $11.25 billion annually in theUnited States) in one study. In another, 35% of people with psoriasis reported the condition affected their career and 20% that it impaired their functioning at work. Work-related stress appears to be greater in men with psoriasis compared to women.

Daily living
Daily living activities such as those requiring the use of hands and walking are impacted by psoriasis in a significant minority of those affected (19% and 14% respectively). Of those who also have psoriatic arthritis, 66% experienced difficulty using their hands and 63% experienced difficulty walking. Sleep is also impacted in many people, with > 20% reporting sleep difficulties associated with the condition. Sitting or standing for long periods of time or performing duties at work is also difficult for some people affected by psoriasis.

Patients with severe psoriasis report their daily living is affected 10% of the time. Treating psoriasis may be time consuming and on average those using topical treatments like skin creams report spending 26 minutes per day applying the treatments. The impact on physical and mental functioning associated with the condition is comparable to that associated with arthritis, depression, cancer and heart disease.

Economic hardship
Psoriasis creates economic hardship for those affected by limiting their ability to work and their income earning capacity, and also due to the cost associated with managing the condition. In a study of patients in theUnited Kingdom, 31% reported the condition caused them financial distress. Treatment may be expensive, particularly new biological therapies.

Psychological health
Psoriasis often has a severe psychological impact and 10% of affected individuals between 18–34 years of age report that they have contemplated suicide. The vast majority report less serious psychological complaints including concern for the future, embarrassment, negative self-image and depressed feelings. Young people (18–34 years old) experience psychological complaints most often, with 81% reporting feeling embarrassed when people saw their skin rash and 75% reporting they felt ugly. In this age group concerns about their condition getting worse in the future were reported by the vast majority (88%). Psychological ill health is more likely if face and hands are affected or the rash is extensive. People who are dependent on alcohol also experience more severe psychological consequences of psoriasis.

Psoriasis is a chronic disease for which there is currently no cure. Those affected will be affected for life. While nothing can cure the immune dysfunction which causes psoriatic skin rash, lifestyle measures reduce the severity of the symptoms for many people.

Avoiding triggers
Avoiding things which trigger psoriasis skin symptoms is an important preventive measure. Common triggers include:

Stress;Some drugs, particularly lithium, beta-blockers, interferons and anti-malarials).

Reducing alcohol consumption
Increasing alcohol consumption is associated with increasing disease severity in men, and both men and women who consume alcohol have an increased risk of psoriasis. Therefore, reducing alcohol consumption is an important behaviour for preventing psoriatic skin rash.

Smoking
Smokers are 1.3 times more likely to develop psoriasis compared to non-smokers. Quitting smoking is a key lifestyle measure for reducing risk of the disease. Quitting smoking (and reducing alcohol consumption) are both important parts of treatment, as use of either reduces the likelihood that treatment will be effective. Individuals who drink too much alcohol are less likely to take their psoriasis medicines correctly and thus are less likely to get the full benefit of their treatment.

Treatment options for people with psoriasis have developed considerably since 2007 and there is now a greater choice of effective therapies on offer. ?The best choice of treatment depends on the individual being treated and factors like:

The extent, severity and site of their psoriatic lesions;Things which trigger psoriasis symptoms;The impact of the disease on quality of life and daily functioning;Comorbid disease; andfactors which may affect treatment compliance.

Although severity of disease influences a person’s psychological response and the quality of life impact they experience, different people respond to psoriasis in different ways. Some people with mild psoriasis are seriously affected by psychological complaints, while others with severe psoriasis have few psychological complaints.

As many different factors influence the best choice of treatment, individuals with psoriasis must speak openly with their doctor about how the disease affects them physically and psychologically. They also need to discuss their treatment priorities with the doctor. While treatment aims to relieve the skin symptoms, people receiving treatment may also be concerned (and in some cases may be more concerned) about improving quality of life, or finding a treatment that is convenient.

It’s also important to speak to the doctor about the aims of treatment and to understand that treatment may alleviate the symptoms of psoriasis, but cannot cure the underlying immune dysfunction which causes the disease. Psoriasis is a life-long condition and is associated with significant morbidity (ill health). However, people with the condition may underestimate the severity of their condition and the impact psoriasis has on their health. For example, in one study 39% of people reported psoriasis affected > 10% of skin surface; however, only 17% classified their disease as severe.

Understanding the severity of the disease is important for ensuring the best treatment is chosen, particularly for those whose psoriasis fails to respond to topical treatments (those applied directly to the skin rash) like creams and gels. These people need to weigh up the risks and benefits of systemic treatments such as medicines and phototherapy, which can have significant side effects and in some cases require frequent doctor appointments. If the impact of psoriasis is underestimated, the benefits of treatment may also be underestimated in the risk benefit analysis.

Pharmacotherapy

Topical treatments
Topical treatments such as creams and gels which are applied directly to the site of psoriatic skin rash are the most commonly used therapies. Topical treatments are typically safe and may be used alone (in cases of mild disease) or in combination with systemic or phototherapies (discussed below) in cases of moderate-severe disease. When deciding which topical treatment is best, it is important to consider the time and difficulty involved in applying the treatment. Preparations which can be applied easily with little mess are recommended, as when the treatment is easy to use, it is more likely to be used frequently and as recommended by the doctor.

Topical treatments are used by 87% of people with severe psoriasis. In cases of mild psoriasis (affecting < 5% of body surface area) they are highly effective. Topical therapies also play an important role in the management of moderate-severe disease because when people use creams and gels, they do not need to use as much medicine or other forms of systemic treatment which have greater side effects and/or are less convenient to use. When used alone, creams and gels are generally not enough to control severe psoriasis.owever the majority of people with severe disease report never having used more intensive photo and systemic therapies. This indicates that those with severe disease there is a greater role for topical treatments to be used in combination with more intensive therapies. Individuals who fail to control their skin rash, should consider and discuss with their doctor, using systemic therapies.??

Phototherapy
Phototherapy should be considered by all adults with extensive psoriatic skin rash which does not improve adequately with topical treatment. Two options are available. UVB therapy (which uses UVB rays) is most appropriate for patients with localised skin rash (restricted to a particular area of the body) while PUVA photochemotherapy is most appropriate for thick psoriatic rash.

Phototherapy is a highly effective form of treatment. 64% of people who had used phototherapy in oneUKstudy reported a good or excellent response. However, only a minority (23%) of people with severe psoriasis have used phototherapy. One thing which limits the use of phototherapy is the need for treatment to be administered in a specialised facility. For the individual being treated this means time, travel and inconvenience. However, in cases of severe disease the benefits of treatment might outweigh the time and inconvenience involved in using it.

Systemic treatments
Systemic treatments are medicines which affect the entire body, not only the site of psoriatic skin lesions. For example, medicines which are swallowed enter the blood stream and are distributed throughout the entire body. They are typically only used to treat psoriatic skin rash which affects > 5% of the body surface area and cannot be adequately controlled using topical or phototherapy. They include:

Corticosteroids (cyclosporin);Folic acid antagonists (methotrexate); andRetinols (acitretin).

Methotrexate is considered the best choice and 70% of people with psoriasis who use it report a good or excellent response to the treatment. However, it is used by only a minority (27%) of people with severe disease.

Biological agents
Novel biologic agents for psoriasis treatment target the processes which underpin the development of psoriatic lesions. Psoriasis is underpinned by a dysfunctional immune response, so biological agents target cells in the immune system including cytokines and T cells. These cells play a role in regulating the immune system’s response, including the dysfunctional (overactive) immune responses which cause psoriatic rash to develop. Targeting these cells modifies (reduces) the immune system response and reduces psoriatic skin rash.??

Because biological agents interfere with the immune system, it is important for people who use these treatments to undergo screening for infectious disease before they begin using them. Any severe infections, including tuberculosis and hepatitis B or hepatitis C should be treated before biological therapy commences.

Alternative therapies
Due to the high rate of side effects with conventional psoriasis treatment, many people with the condition consider using alternative therapies. In one survey almost half (43%) of the respondents reported trying over-the-counter medications or alternative therapies including herbal remedies, acupuncture and relaxation to treat psoriasis. 10% of the people were using some form of alternative therapy at the time of the survey. The majority (52%) reported no improvement in their condition with use of alternative therapy. There is little evidence to suggest that alternative therapies are effective in treating psoriasis. However, those who are interested in trying alternative therapies should discuss the available evidence with their doctor.

Diet
Dietary modifications may reduce the severity of psoriatic rash; however, evidence is limited. As the condition is underpinned by inflammation, an anti-inflammatory diet may be of benefit. Such a diet is based on the consumption of omega-3 fatty acids, whole grains, legumes, and fresh fruit and vegetables and avoidance of omega-6, saturated and trans fats and processed foods. It should also include the use of spices with anti-inflammatory properties such as ginger, cumin, basil and turmeric.

Identifying and avoiding food allergens which trigger psoriasis is another possible strategy. Many people with psoriasis are gluten intolerant and a gluten-free diet may be beneficial for this group. Obesity is a risk factor for the condition and maintaining a healthy weight is important.

Dietary supplements
Dietary supplements may also be beneficial for people with psoriasis. Oral (by mouth) or intravenous (injected into a vein) supplementation with fish oil is one supplement with possible benefits. Topical fish oil therapy is an option but most people find it unpleasant to use because of the odour of the oil. Folic acid supplementation is essential for people using the folic acid antagonist, methotrexate. Oral and topical vitamin D have also proven effective in treating psoriasis. Recent evidence for a dietary supplement based on proteins isolated from cows is promising; the therapy is safe and significantly reduced disease severity compared to no treatment in one study.

Topical therapies
A range of non-pharmaceutical topical therapies have also been shown to improve psoriasis. Cream containing aloe vera extract reduced the extent of psoriatic lesions compared to no treatment in one study. Emollients (skin softeners), particularly those containing ceramides (fatty acids which hold water), regulate the water-holding capacity of the skin and have been show to reduce the scaliness of psoriasis.

Lifestyle treatments
Lifestyle measures which may assist in the treatment of psoriasis include:

Bathing and sun bathing at theDead Seafor a period of 4 weeks;Increasing physical activity, particularly outdoor physical activity;Weight management for those with excessive body mass index (BMI) (who are overweight or obese);Quitting smoking;Reducing alcohol consumption; andStress management.

Treatment of comorbid conditions
Psychotherapy is essential for people who experience ongoing psychological difficulties as a result of their psoriasis. Medical treatment may not be appropriate as many medicines used for psychological conditions may worsen psoriasis. People who also have alcohol dependence disorder (are alcoholic) are less likely to respond to treatment and less likely to comply with their treatment plan (e.g. take their medicine as scheduled). These people may also need to access alcohol rehabilitation services.

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Living with Hyperhidrosis (Excessive Sweating)

Hyperhidrosis is a condition characterised by excessive perspiration in response to non-thermoregulatory stimuli; that is, in response to stimuli other than heat. It can be further categorised as:

Focal hyperhidrosis, characterised by excessive sweating with no apparent cause, at one or more discrete anatomical sites, most commonly the: Armpits- axillary hyperhidrosis;Hands- palmar hyperhidrosis;Feet- plantar hyperhidrosis; andFace- craniofacial hyperhidrosis; orGeneralised hyperhidrosis characterised by excessive sweating affecting the entire body, usually as a result of an underlying medical condition.

Hyperhidrosis is a highly prevalent condition. One US study reported 2.8% of the population experienced primary hyperhidrosis. However, it is also under-recognised and the majority of individuals affected by hyperhidrosis never seek medical advice about their condition.

Hyperhidrosis is a benign disorder (of no danger to health); however, it carries serious implications for an individual’s quality of life and psychosocial wellbeing. Improving quality of life is a key treatment goal. The condition impairs daily activities and in doing so has a negative impact on quality of life. Women report being more affected compared to men. Similarly, individuals who develop hyperhidrosis early in life, compared to those who develop the condition later, also report more significant impairment. Those with axillary hyperhidrosis appear to be particularly affected in terms of quality of life, followed by those with palmar hyperhidrosis.?

Quality of life and psychosocial wellbeing

The overwhelming majority (90%) of hyperhidrosis patients report that the condition affects their emotional state. In one survey most patients (> 50%) reported feeling less confident as a result of their condition. Frustration undertaking daily activities, unhappiness and depression and embarrassment are also commonly reported by individuals with hyperhidrosis. For example, in a US survey, one-third of individuals affected by hyperhidrosis reported that their sweating was barely tolerable or intolerable and interfered with their daily living. Another survey indicated that the quality of life implications of the condition were greater than those associated with chronic and acute conditions including end-stage kidney disease, rheumatoid arthritis and multiple sclerosis. Individuals with affected armpits appear to be most affected by associated psychological complaints. For example, one study reported people with axillary hyperhidrosis were significantly more likely to be unhappy or depressed than those with palmar hyperhidrosis.

Social life

The perceived impact of hyperhidrosis is strongly associated with the impact the condition has on a person’s social functioning. Many people with hyperhidrosis feel embarrassed by their condition in social situations. Those with palmar hyperhidrosis may be embarrassed to shake hands, particularly when meeting someone for the first time, because their palms are cold, wet and slippery. Wet palms may be taken by others as a sign of anxiety, and for individuals with palmar hyperhidrosis this can be an additional source of anxiety which worsens the condition. The vast majority of people with affected palms avoid shaking hands as a result of their condition. They may face stigma and discrimination when they need to shake hands.

Individuals with affected armpits may feel embarrassed by sweat-damp clothing, or needing to change clothes frequently. They may avoid public places or social gatherings as a result of their condition or be limited in the choice of clothing they can wear as a result of hyperhidrosis.

Recreational activities

Hyperhidrosis may limit involvement in sporting or leisure activities for some and others may change the type of leisure activities they participate in due to their sweating symptoms. For example, those with palmar hyperhidrosis may be unable to participate in sports requiring manual dexterity because their hands are damp and slippery. Playing a musical instrument is also difficult for individuals with palmar hyperhidrosis. Properly hydrated skin on the palms helps with grip and, therefore, the excessive hydration of hyperhidrosis interferes with all tasks requiring manual dexterity.

Intimate relationships

Hyperhidrosis may also impact on an individual’s ability to engage in intimate relationships and perform sexual activities. In one study the majority of people affected by hyperhidrosis (59%) reported that the condition considerably limited their ability to develop personal relationships, while 34% reported hyperhidrosis adversely affected their sexual activities.?

Work productivity and career development

Hyperhidrosis interferes with work activities and limits occupational opportunities, with negative economic implications for some people affected. Office workers with palmar hyperhidrosis may find dampness of the palms makes using a keyboard difficult or results in sweat-stained books and papers. Manual labourers may have a greater risk of injury, for example by electric shocks, or be less productive because palmar hyperhidrosis impairs their manual dexterity. They may be unable to grip or use occupation-specific tools or devices such as electronic equipment or weapons. This may, for instance, limit their ability to take up a position in the armed services or police. Of those affected by hyperhidrosis, 19% report that the condition directly influenced their choice of career.

Axillary hyperhidrosis is also reported by the majority (> 80%) of affected individuals to interfere with work activities. The condition may limit the amount of time people spend at work. It may also be a source of anxiety which prevents them performing some work tasks. For example they may be too embarrassed to make public presentations because of their excessive sweating. As with palmar hyperhidrosis, those with affected axillae may find their career choices limited due to social embarrassment. Reports from individuals affected by hyperhidrosis have indicated that they needed to change their work habits, are less effective, accurate and/or careful at the work they do, and/or accomplish less work because of their condition.

Diet

Some individuals affected by hyperhidrosis find their condition is aggravated by certain foods and that they have to modify their diet as a result. For example, they may need to avoid alcoholic or caffeinated beverages or spicy foods. However, evidence suggests that dietary factors trigger sweating in only a small proportion of people with hyperhidrosis.

Comorbid dermatological conditions

Hyperhidrosis is associated with an array of dermatological (skin) conditions including dermatitis, fungal infections such as candidiasis and bacterial infections. Constant dampness associated with the condition can result in skin maceration (softening) and the overgrowth of fungi or bacteria. For example, hyperhidrosis is associated with maceration of the skin of the soles which may result in bromhidrosis (offensive odour) or infection.

Physical discomfort

Dampness resulting from hyperhidrosis causes physical discomfort for many people. One study noted a 14 year old who developed poor posture as a result of slouching in an attempt to hide sweat stains on her clothing.

Expense

Excessive sweating can stain and damage clothing and shoes and individuals with hyperhidrosis may spend thousands of dollars each year to cover the costs of maintaining and replacing sweat-damaged clothes and shoes. Treating the condition may also create significant expense, and effective treatments including botulinum toxin injections are limited because of the associated expense.

Seeking treatment for hyperhidrosis is an important aspect of minimising the impact of the condition. Most people do not discuss their excessive sweating with a medical professional and thus do not treat the condition. In many cases this is because they are unaware that they have a treatable medical condition.Evidence suggests that only one-third of affected individuals receive treatment for hyperhidrosis. Detection and management of the condition can significantly improve quality of life and social wellbeing. All individuals who find excessive sweating interferes with their day-to-day life should consult their doctor.

Doctors may also notice symptoms of excessive perspiration (e.g. fungal infection, damp clothing) when an individual consults for another health problem. In these cases the doctor may also make enquiries about sweating, if they suspect hyperhidrosis. A tool such as the hyperhidrosis severity scale may be used to investigate sweating symptoms.

A range of lifestyle measures can be taken to minimise the impact of hyperhidrosis on daily living and help individuals cope with their condition. Appropriate measures vary depending on the anatomical sites affected.

Maintaining good hygiene

Maintaining good hygiene is important for individuals affected by hyperhidrosis. They should bath daily and pay special attention to drying affected areas of skin (particularly the feet) to reduce bacterial concentrations. Affected feet should be aired regularly.?

Absorbent pads

Individuals with axillary hyperhidrosis may benefit from using absorbent pads to prevent sweat from soaking through clothing.

Changing clothing

Axillary hyperhidrosis can result in sweat-soaked clothing and individuals who experience this may need to carry extra clothing to allow them to change as needed. One study of individuals with axillary hyperhidrosis reported that 70% needed to change their clothing at least twice a day.

Selecting appropriate clothing and footwear

Individuals with hyperhidrosis affecting the armpits may benefits from wearing clothing made from breathable materials such as silk and cotton, and avoiding manmade fibres and tight or restrictive clothing. Wearing black or white clothes may help reduce the visibility of sweat stains. Those with affected feet should wear thick socks made from cotton or wool, and rotate their socks and shoes. Shoes made from leather, mesh or canvas are most appropriate and those made from synthetic materials should be avoided by individuals with plantar hyperhidrosis.

Wearing gloves

Wearing gloves may make it easier for those with palmar hyperhidrosis to complete some tasks.

Relaxation

In some cases hyperhidrosis occurs in response to emotional stimuli. Practising relaxation techniques may assist individuals to cope with emotional stimuli that trigger sweating.

Rehydration

Excessive sweating may lead to dehydration if fluids are not replaced. Ensuring proper hydration is maintained is therefore an important component of managing the condition.

A range of treatment options to reduce sweat production are available for individuals with hyperhidrosis. Treatment typically begins with simple, non-invasive options (e.g. topical antiperspirants) and progresses to more difficult treatments when these fail. Effective treatment, whether simple or invasive, is associated with improved quality of life.

Psychotherapy

Hypnosis, psychotherapy? and biofeedback are only effective in treating a limited number of hyperhidrosis cases. For example, one study reported clinical improvement in sweating in 11 of 14 people treated with biofeedback for a 6 week period. Effective treatment typically leads to quality of life improvements; however, there is no direct evidence of the effects of psychotherapies on quality of life in people affected by hyperhidrosis.

Behavioural therapy

Behavioural therapies including assertiveness training and systematic desensitisation (to help overcome anxiety) have been reported as treatment options for hyperhidrosis. Cognitive behavioural therapy may be an effective addition to treatment in those with symptoms of anxiety. Effective treatment typically leads to quality of life improvements although there is no direct evidence of the effects of behavioural therapies on quality of life in hyperhidrosis.

Topical antiperspirants

Topical antiperspirants are a treatment option for individuals with focal hyperhidrosis, particularly when the armpits are affected. One study reported significant improvements in quality of life following treatment with topical antiperspirants.

Iontophoresis

Iontophoresis, a treatment which involves the introduction of ions to affected areas of skin via application of an electric current, is often effective in treating palmar or plantar hyperhidrosis, as these body parts can be easily submerged for the treatment. It provides temporary symptom relief and maintenance therapy is usually required. One study reported significant quality of life improvements following iontophoresis.

Botulinum toxin A

Injections of botulinum toxin A to affected areas of skin have been demonstrated to reduce the symptoms of hyperhidrosis. In Australia,?Botox is approved for use as a treatment for cases of axillary hyperhidrosis. Several studies have reported that the treatment also improves quality of life and/or psychosocial wellbeing. For example, one study reported a reduction in anxiety, depression and social phobia following botulinum toxin A treatment, and also that quality of life improved.

Oxybutynin

Oxybutynin (an anticholinergic medicine which interferes with the transmission of nervous signals) is a treatment option for generalised hyperhidrosis underpinned by chronic medical conditions such as diabetes. One study reported significant improvements in individuals with generalised hyperhidrosis following oxybutynin treatment.

Thoracic sympathectomy

Thoracic sympathectomy is a minimally invasive procedure which permanently resolves excessive sweating for the majority of people treated. In cases of palmar hyperhidrosis the treatment has been shown to improve quality of life, even if compensatory sweating (sweating at previously unaffected body sites) occurs following surgery.The surgery is also effective in permanently improving axillary hyperhidrosis with low (11%) recurrence rates. Quality of life improvements are sustained for at least 5 years following surgical treatment.

Other surgical treatments

Subcutaneous curettage (removal of tissues from under the skin) may be used to treat hyperhidrosis of the axillae and was reported to significantly improve quality of life in one study.?

Article kindly reviewed by

Dr Karl Ng MB BS (Hons I) FRCP FRACP CCT Clinical Neurophysiology (UK)
Consultant Neurologist and licensed botulinum toxin administrator,
Sydney North Neurology and Neurophysiology (download referral form and map)
Conjoint Senior Lecturer, University of Sydney; and Editorial Advisory Board Member of the Virtual Neuro Centre.

Eisenach JH, Atkinson JLD, Fealey RD. Hyperhidrosis: Evolving Therapies for a Well-Established Phenomenon. Mayo Clinical Proc. 2005; 80(5): 657-66. [Abstract | Full Text]?Kumagai K, Kawase H, Kawanishi M. Health-related quality of life after thoracoscopic sympathectomy for palmar hyperhidrosis. Ann Thorac Surg. 2005; 80: 461-66. [Abstract Full Text]International Society for hyperhidrosis. About hyperhidrosis- the effect on patients’ lives- quality of life surveys. 2012. [cited 2 January 2012]. Available from: [URL Link]?International Society for hyperhidrosis. About hyperhidrosis- the effect on patients’ lives- social embarrassment and psychological effects. 2012. [cited 2 January 2012]. Available from: [URL Link]?Haider A, Solish N. Focal hyperhidrosis- diagnosis and management. Canadian Medical Association Journal. 2005; 172(1): 69-75. [Full Text]Hamm H, Naumann MK, Kowalski JW, et al. Primary focal hyperhidrosis. Disease characteristics and functional impairment. Dermatol. 2006; 212: 243-53. [Full Text]Benhanian A, Solish N. Hyperhidrosis: Sweating out the details. Can J CME. 2004; June: 77-81. [Full Text]Collin J, Whatling P. Treating hyperhidrosis: Surgery and botulinum toxin are treatments of choice in severe cases. BMJ. 320: 1121 [Abstract]Weber A, Heger S, Sinkgraven R, et al. Psychosocial aspects of patients with focal hyperhidrosis. Marked reduction of social phobia, anxiety and depression and increased quality of life after treatment with botulinum toxin A. Br J Dermatol. 2005; 114: 342-5. [Abstract]Cina CS, Cona MM, Clase CM. Endoscopic thoracic sympathectomy for hyperhidrosis: technique and results. J Minim Access Surg. 2007; 3(4): 132-40. [Full Text]International Society for hyperhidrosis. About hyperhidrosis- the effect on patients’ lives- occupational tasks and activities of daily living. 2012. [cited 2 January 2012]. Available from: [URL Link]?Amini M, Harmsze AM, Tupker RA. Patient’s Estimation of Efficacy of Various Hyperhidrosis Treatments in a Dermatological Clinic. Acta Derm Venereol. 2008; 88: 356-62. [Full Text]International Society for hyperhidrosis. About hyperhidrosis- the effect on patients’ lives- physical discomfort. 2012. [cited 2 January 2012]. Available from: [URL Link]Gelbard CM, Epstein H, Hebert A. Primary Pediatric Hyperhidrosis: A Review of Current Treatment Options. Pediatric Dermatol. 2008; 25(6): 591-8. [Abstract | Full Text]Wang R, Solish N, Murray CA. Primary focal hyperhidrosis: diagnosis and management. Deramtol Nurs. 2008; 20(6): 467-70. [Abstract]National Health Service. Treating hyperhidrosis. 2011. [cited 4 January 2012] [URL Link]Moore A. Clinical vignette: hyperhidrosis. University of California- Los Angeles. Available from: [URL Link] Hashmonai M, Kopelman D, Assalia A. The treatment of primary palmar hyperhidrosis: a review. Surg Today. 2000; 30(3): 211-18. [Abstract]Duller P, Gentry WD, Use of biofeedback in treating chronic hyperhidrosis: a preliminary report. Br J Dermatol. 1980; 103(2): 143-46. [Abstract]Bar LHJ, Kuypers BRM. Behavioural therapy in dermatological practice. Br J Dermatol. 1973; 88(6): 591-98. [Abstract]Campos JR, Kauffman P, Campos Werebe E, et al. Questionnaire of quality of life in patients with primary hyperhidrosis. J. Pneumologia. 2003; 29(4). [Full Text]?Wolosker N, Campos JR, Kauffman P, et al. Evaluation of quality of life over time among 453 patients with hyperhidrosis submitted to endoscopic thoracic sympathectomy. J Vasc Surg. 2012; 55(1): 154-6. [Abstract]

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Living with Schizophrenia

The term schizophrenia was first coined by Swiss psychiatrist?Eugen Bleuler to describe the presence of schisms between thought, emotion and behaviour. Clinically, schizophrenia is a disturbance lasting for at least 6 months and including at least one month of at least two of the following:

Schizophrenia remains one of the top causes of disability in the world, despite more than five decades of pharmacological and psychosocial interventions. The impairments faced by people with schizophrenia are widespread, affecting social, occupational and independent living activities. People with schizophrenia commonly have disabilities in partner relationships, work roles, social withdrawal, household participation, general interests, self care and social friction. These disabilities are especially common among young and middle aged adults, and occur even in people responding to treatment for psychosis.

A long term study looked at the change in social disability of people who had?a first episode psychosis. It found that the level of social disability for a particular individual fluctuated with time, and many?individuals experienced different levels of disability. About one third of the people involved in the study improved considerably over?15 years, and 40% had little or no disability at the end. However, one out of seven did not improve.

Several scientific studies have shown that most patients with schizophrenia are noncompliant with their medications.?This means that they either do not take the correct dose of their medications, or do not take their medication regularly. Several studies have shown that?90% or more of?schizophrenic patients do not take their medication as directed. There are various reasons why patients do not take their medication, including forgetting to pick up a refill, cost, or an intentional decision to not take medication.

Patients who do not take their medication as directed often experience poorer outcomes, including increased hospitalisation rates. A large study used information from pharmacists to identify patients who did not take their medication as directed. They found that patients with good compliance had the lowest rates of hospital admission.?As compliance decreased, the rates of hospital admissions increased. Once admitted to hospital, those who were less compliant stayed longer?in hospital.?

This information will be collected for educational purposes, however it will remain anonymous.

You should consult your doctor if you or someone close to you notices unusual behaviours that might indicate signs of early psychosis. There are programs, such as the?Early Intervention in Psychosis (EIP), which use a range of approaches to intervene at the earliest opportunity.?Early intervention helps to improve symptoms, functional capacity and quality of life. A recent review found this method effective in delaying transition to psychosis, reducing duration of untreated psychosis, preventing relapse, reducing hospital admissions and rates of suicide,?and reducing treatment costs.

You should also consult your doctor if?you are experiencing side effects from your medication, or are?having difficulty taking your medication in a regular fashion. Some common side effects are:

Consult your doctor if you have any concerns related to schizophrenia, or any?other health or mental conditions.

This tolerability tool is based on a self-rating scale designed by Waddell and Taylor1 to assess if you are experiencing undesirable side effects from your antipsychotic medication.

This tolerability tool is based on a self-rating scale designed by Waddell and Taylor1 to assess if you are experiencing undesirable side effects from your antipsychotic medication.

Absent/mild side effects

You may be experiencing side effects from your current medication. It would be advisable to discuss this with your GP or psychiatrist to discuss your medication options. Medicating with minimal side effects is optimal to ensure correct use and prevention of relapse.

Moderate side effects

You are experiencing what may be side effects from your current medication. You should discuss this with your GP or psychiatrist to discuss your medication options. Medicating with minimal side effects is optimal to ensure correct use and prevention of relapse.

Severe side effects

You are experiencing what may be side effects from your current medication. Discuss this with your GP or psychiatrist to discuss your medication options. Medicating with minimal side effects is optimal to ensure correct use and prevention of relapse.

It seems that one or more of the side effects you are experiencing is distressing you. You may like to discuss this with your doctor to see if there are any other medications and/or doses that better suit your situation.

Reference
Waddell L, Taylor M. A new self-rating scale for detecting atypical or second-generation antipsychotic side effects. J Psychopharmacol 2008; 22: 238-243.

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?

There are several things that can be done to help reduce the impact of schizophrenia on your lifestyle.?These include:

Early diagnosis and comprehensive treatment of the first episodeComprehensive care, especially in the first 3–5 years following diagnosis. The course of illness is strongly influenced by what happens in this critical period.Antipsychotic medicationCareful monitoring of side effects Psychosocial interventions should be routinely available to all patients and their families. These include: A positive social and cultural environment, including: Adequate shelterFinancial securityAccess to meaningful social roles Availability of social supportTailoring of interventions to phase and stage of illness, and to gender and cultural backgroundMaintenance of good physical healthQuality medical care involving general practitioners and psychiatrists.

For more information about schizophrenia and its treatments, videos and useful tools, see schizophrenia.?

Sadock BJ, Kaplan HI, Sadock VA. Kaplan & Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry [9th edition]. Philadelphia: Lippincott Williams & Wilkins; 1998.First MB, Tasman A [eds]. DSM-IV-TR Mental Disorders: Diagnosis, Etiology and Treatment. Chichester: Wiley & Sons; 2004.Murray CJ, Lopez AD. Global mortality, disability, and the contribution of risk factors: Global Burden of Disease Study. Lancet. 1997; 349: 1436-42.Bowie CR, Reichenberg A, Patterson TL, Heaton RK, Harvey PD. Determinants of real-world functional performance in schizophrenia subjects: Correlations with cognition, functional capacity and symptoms. Am J Psychiatry. 2006; 163(3): 418-25.Wiersma D, Wanderling J, Dragomirecka E, Ganev K, Harrison G, an der Heiden W, et al. Social disability in schizophrenia: Its development and prediction over 15 years in incidence cohorts in six European countries. Psychol Med. 2000; 30(5): 1155-67.Harvey PD, Green MF, Keefe RS, Velligan DI. Cognitive functioning in schizophrenia:?A consensus statement on its role in the definition and evaluation of effective treatments for the illness. J Clin Psychiatry. 2004; 65(3): 361-72.Docherty JP, Grogg AL, Kozma C, Lasser R. Antipsychotic maintenance in schizophrenia: Partial compliance and clinical outcome. Presented at?the 41st?Annual Meeting of the American College of Neuropsychopharmacology. San Juan, PR: Dec 8-12, 2002. ?McCombs JS, Nichol MB, Stimmel GL, Shi J, Smith RR. Use patterns for antipsychotic medications in Medicaid patients with schizophrenia. J Clin Psychiatry. 1999; 60(Suppl 19): 5-11.Valenstein M, Copeland LA, Blow FC, McCarthy JF, Zeber JE, Gillon L, et al. Pharmacy data identify poorly adherent patients with schizophrenia at increased risk for admission. Med Care. 2002; 40(8): 630-9.Weiden PJ, Kozma C, Grogg A, Locklear J. Partial compliance and risk of rehospitalisation among California Medicaid patients with schizophrenia. Psychiatr Serv. 2004; 55(8): 886-91.Glazer WM, Byerly MJ. Tactics and technologies to manage nonadherance in patients with schizophrenia. Curr Psychiatr Rep. 2008; 10(4): 359-69.Patel MP, David AS. Medication adherence: Predictive factors and enhancement strategies. Psychiatry. 2007; 6(9): 357-61.Ricciardi A, McAllister V, Dazzan P. Is early intervention in psychosis effective? Epidemiol Psichiatr Soc. 2008; 17(3): 227-35.Waddell L, Taylor M. A new self-rating scale for detecting atypical or second-generation antipsychotic side effects. J Psychopharmacol. 2008; 22(3): 238-43.Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines?for the treatment of schizophrenia and related disorders. Aust N Z J Psychiatry. 2005; 39(1-2): 1-30.

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