Evaluating the effectiveness of psychological and/or educational interventions in psoriasis: a narrative review

Non-pharmacological interventions for patients with psoriasis: a scoping review

OBJECTIVES

Healthcare ultimately aims to eradicate diseases and restore normality to people's lives. However, until this is achieved for every person, there is a need to support and assist patients with psoriasis using non-pharmacological interventions. These 'adjuvant' approaches have received little attention, whereas dermatologists and researchers strive for better pharmacological therapy. Here, we aimed to perform a scoping review to identify and catalogue non-pharmacological interventions for patients with psoriasis.

DESIGN

A scoping review.

SETTING

All healthcare settings.

SEARCH STRATEGY

EMBASE, PubMed, CINAHL, PsycINFO and Scopus databases were searched from their inception to June 2022. Irrespective of the study type, the studies included non-pharmacological interventions for patients with psoriasis. This theme was extracted from the included articles. Two reviewers independently screened and analysed the data.

RESULTS

From 1322 initial records, 71 studies were identified and analysed. Non-pharmacological interventions for patients with psoriasis include two levels: organisational and individual. The organisational non-pharmacological interventions included the nationwide healthcare model (PsPSP, ProvenCare, German PsoHealth and Psoriasis Network, IMPROVE model and PsoWell clinic), innovative teledermatology models (mHealth app, electronic Targeted Intervention for Psoriasis study and therapist-guided internet-based cognitive and behavioural treatments) and multidisciplinary interventions. The individual non-pharmacological interventions included educational interventions (therapeutic patient education, psychoeducational intervention and self-management education), psychosocial interventions (cognitive and behavioural treatments, self-help and peer-to-peer support programmes) and others (happify and motivational interviewing-based training).

CONCLUSIONS

Based on previous literature, a nationwide healthcare model protocol was constructed for patients with psoriasis. This provided the direction for developing a new psoriasis healthcare model and a basis for summarising the non-pharmacological interventions for patients with psoriasis, which helps them adjust to changes in the skin disease.

The Effects of Interacting With a Paro Robot After a Stressor in Patients With Psoriasis: A Randomised Pilot Study

Objective

Stress can play a role in the onset and exacerbation of psoriasis. Psychological interventions to reduce stress have been shown to improve psychological and psoriasis-related outcomes. This pilot randomised study investigated the feasibility of a brief interaction with a Paro robot to reduce stress and improve skin parameters, after a stressor, in patients with psoriasis.

Methods

Around 25 patients with psoriasis participated in a laboratory stress task, before being randomised to either interact with a Paro robot or sit quietly (control condition) for 30 min. Raman spectroscopy and trans-epidermal water loss were measured at baseline, after the stressor and after the intervention as indexes of acute skin changes. Psychological variables, including self-reported stress and affect, were also measured at the three time-points.

Results

No statistically significant differences between the two conditions were found for any of the outcomes measured. However, effect sizes suggest significance could be possible with a larger sample size. Changes in the psychological and Raman spectroscopy outcomes across the experimental session were found, indicating the feasibility of the procedures.

Conclusion

This pilot study showed that a brief interaction with a Paro robot was a feasible intervention for patients with psoriasis, but future trials should broaden the inclusion criteria to try to increase recruitment rates. Studying people who are highly stressed, depressed or who are stress-responders may increase the power of the intervention to show effects using a longer-term intervention.

HautTief Multidisciplinary Educational Program for Patients with Psoriasis or Atopic Dermatitis: A Randomized Controlled Study

Background

Improving health-related quality of life (HRQoL), disease severity, and treatment adherence through patient education is an increasingly important, yet relatively new area in dermatology. This randomized controlled trial aims to contribute to this growing area of research by exploring the effects of a 9-week educational program for patients with chronic skin diseases.

Objective

The aim of the study was to evaluate the effect of a multidisciplinary educational program on HRQoL and disease severity in patients with psoriasis or atopic dermatitis (AD).

Methods

Sixty-four patients with diagnosed psoriasis or AD were recruited from University Hospital Zurich and randomized (1:1) to the intervention or control group. To assess HRQoL, the following self-reported questionnaires were used: Dermatology Life Quality Index (DLQI), Skindex-29, EuroQol-5D (EQ-5D), RAND 36-Item Short Form Survey (SF-36), and Beck Depression Inventory (BDI) to measure depression symptoms. Psoriasis Area and Severity Index (PASI) and the Eczema Area and Severity Index (EASI) were used to capture disease extent. These scores were assessed at four study visits, which were performed at baseline and 3, 6, and 9 months after the start of the program.

Results

At month 6, an improvement of at least 25% in BDI was recorded in 15 (68.2%) of 22 patients in the intervention group and 6 (27.3%) of 22 patients in the control group (difference 40.9%, p = 0.016). 53.3% (16 of 30) of patients achieved an improvement in one subdomain of the SF-36 score (role limitations due to emotional problems) at 6-month follow-up, compared with 23.1% (6 of 26) of those not attending the educational program (difference 30.2%; p = 0.042). No significant differences in DLQI, Skindex-29, EQ-5D, PASI, and EASI between both groups at the three time points were found.

Conclusion

An educational program may improve HRQoL and depression status of patients with psoriasis or AD.

Does the lifestyle of patients with psoriasis affect their illness?

Psoriasis is one of the most common chronic, incurable inflammatory skin diseases, affecting 2–4% of the general population. Etiopathogenesis of this disease remains unclear. It is widely considered to be a multifactorial disorder caused by the interaction between inherited susceptibility alleles and environmental risk factors, such as lifestyle, diet, stimulants, foci of inflammation, and psychological factors. The widespread prevalence of psoriasis is a very significant health and socioeconomic problem. Treatment of psoriasis is based on relieving the acute symptoms of the disease. Despite the implementation of many therapeutic options, including biological treatment, effectiveness of these options is not always sufficient, or in some patients it is not satisfactory. In order to properly control the symptoms of the disease, the patient should be told that the therapeutic effect is achieved not only by pharmacotherapy but also by introducing appropriate healthy habits in everyday life. This article discusses the importance of patient-controlled factors that affect the severity of psoriasis. Theimportance of regular exercise, smoking avoidance, and reduced alcohol consumption is explained, as well as the importance for psoriasis treatment of psychotherapy and spa therapy. Understanding the essence of these factors in the treatment of psoriasis is important in achieving satisfactory therapeutic effects.

Hypochondriasis and Personality Traits of Patients with Chronic Plaque Psoriasis

BACKGROUND

Plaque psoriasis has been associated with anxiety, depression, suicidal ideation and various personality traits. However, studies on hypochondriasis, i.e. the belief of serious illness despite having no or only mild symptoms, are currently scarce.

OBJECTIVE

The aim of this study was to assess hypochondriasis and personality traits in psoriasis patients using the Minnesota Multiphasic Personality Inventory-2 (MMPI-2).

METHODS

We conducted an observational study on patients with plaque psoriasis who underwent MMPI-2 testing. Demographic and clinical data, including comorbidities, alcohol consumption, and smoking, were collected.

RESULTS

A total of 136 consecutive psoriatic patients were included. The mean age (±SD) was 53.7 (±13.5), mean PASI (Psoriasis Area Severity Index) was 12.4 (±9.9), and mean disease duration was 23.3 (±15.7) years. Pathologically elevated scores in the Hypochondriasis scale were observed in 27.9% of patients. Furthermore, in a few other MMPI-2 scales (Anxiety, Fears and Negative Treatment Indicators) ≥25% of patients obtained pathologically elevated scores. Conversely, the scales that had the highest proportion of low scorers were Ego Strength and Dominance. At regression analysis, higher psoriasis severity and female gender were associated with higher scores in the Hypochondriasis scale (p = 0.03 and 0.001). Finally, 72.8% reported any alcohol consumption and 8.1% heavy alcohol consumption.

CONCLUSION

About one third of patients with psoriasis have high scores in the MMPI-2 hypochondriasis evaluation scale. Poor individual coping resources also appeared to be distinctive psychological features in a significant proportion of psoriatic patients.

Analyzing the value of an educational program for psoriasis patients: a prospective controlled pilot study

Background

Psoriasis is a chronic inflammatory skin disease associated with a reduced life-quality. Severe disease forms put the patients at risk for life-treating cardiovascular events, metabolic, and other immune-mediated disorders. Psoriasis patients are often not sufficiently informed about their condition leading to suboptimal treatment adherence and, consequently, worse patient outcome. We investigated the value of an educational program on knowledge and self-expertise about the disease in psoriasis patients in general and dependent on age and disease duration.

Methods

Regular visit psoriasis-patients were asked to participate and choose to receive an additional educational program or not. Participating patients (n = 53) filled out two questionnaires: one at study inclusion and one at the next regular visit or after the absolved educational program. Surveys included disease knowledge assessment and numeric rating scales (0–10) for self-expertise about the disease, therapy adherence, and therapy satisfaction. The Dermatology Life Quality Index (DLQI) was used to investigate the quality of life.

All continuous parameters were examined for statistically significant differences by paired t-test or unpaired t-test. Continuous parameters without Gaussian distribution were analyzed with the Wilcoxon matched pairs test or the Mann-Whitney test. For all categorical parameters, Fisher’s exact test was used.

Results

Patients who chose to be educated (n = 24) showed a significant increase in knowledge, self-expertise about the disease and amelioration of general health. No positive short-term effects were seen on the quality of life and therapy adherence. Analyzing the effect of age and disease duration, the educational program led to significant improvement of the emotional well-being in older patients (≥50 years) and with a longer disease duration as well as significant amelioration of the self-expertise about psoriasis in younger patients (< 50 years).

Conclusions

Patients who chose to participate in an educational program show a higher gain in knowledge and self-expertise about the psoriatic disease. Educational program thus might have a positive effect on the long-term management of psoriasis. Further long-term studies are needed to provide evidence for the influence educational programs have on outcome, quality of life, and treatment adherence of psoriatic patients.

Trial registration

Deutsches Register Klinischer Studien DRKS00017318 (09.10.2019), retrospectively registered.

Psychological Therapies in Management of Psoriatic Skin Disease: A Systematic Review

BACKGROUND

Psoriasis is a chronic, immune-mediated skin disease shown to have a multifaceted relationship with psychological factors. Because these factors have been shown to both worsen and result from psoriasis, an increasing number of studies have sought to investigate the efficacy of various psychological interventions in psoriasis management.

METHODS

A systematic review of PubMed^® and Scopus^® databases was performed for studies investigating psychological interventions in psoriasis management published from 1 January 1990 through 4 November 2018. Primary articles published in English and conveying physical treatment outcomes were included, whereas articles not describing clinical outcomes were excluded. Studies supporting intervention efficacy were graded with a level of evidence according to the Scottish Intercollegiate Guidelines Network levels of evidence.

RESULTS

A total of 28 reports studying 27 unique sets of patients receiving psychological therapies in psoriasis management were identified, including three case reports and series and 24 clinical trials, investigating 1522 patients in total. Cognitive behavioral therapy and its variants, biofeedback, meditation and mindfulness-based therapies, hypnosis, music resonance therapy, motivational interviewing, emotional disclosure, and educational and multidisciplinary approaches have been studied in the treatment of psoriasis. Although 16 randomized controlled trials were included in this review, literature is limited by heterogeneity of methodology, analyses, and outcomes. Only 4 of 27 studies (three of which investigated cognitive behavioral therapy) were rated a level of evidence of 1+ or greater. Studies, overall, have sample sizes often < 50 patients, lack follow-up past 12 months, and have attrition rates > 20%.

CONCLUSIONS

Based on assigned levels of evidence, the most promising methods of psychological intervention in psoriasis include cognitive behavioral therapy, mindfulness-based therapies, motivational interviewing, and educational and interdisciplinary interventions. Further study is needed to determine the efficacy, practicality, and economic feasibility of these treatment options for patients with psoriasis.

Multidisciplinary Management of Spondyloarthritis-Related Immune-Mediated Inflammatory Disease

Introduction

Immune-mediated inflammatory diseases (IMIDs) are chronic autoimmune conditions that share common pathophysiologic mechanisms. The optimal management of patients with IMIDs remains challenging because the coexistence of different conditions requires the intervention of several specialists. The aim of this study was to develop a series of statements defining overarching principles that guide the implementation of a multidisciplinary approach for the management of spondyloarthritis (SpA)-related IMIDs including SpA, psoriasis, psoriatic arthritis, Crohn’s disease, ulcerative colitis and uveitis.

Methods

A Delphi consensus-based approach was used to identify a core set of statements. The process included development of initial questions by a steering committee, an exhaustive search of the literature using complementary approaches to identify potential statements and two Delphi voting rounds for finalization of the statements.

Results

Consensus was achieved on the related nature of IMIDs, the existence of a high prevalence of multiple IMIDs in a single patient and the fact that a multidisciplinary approach can result in a more extensive evaluation and comprehensive approach to treatment. The goals of a multidisciplinary team should be to increase diagnosis of concomitant IMIDs, improve the decision-making process, and increase patient satisfaction and adherence. Early referral and diagnosis, early recognition of concomitant IMIDs and optimizing treatment to improve patient quality of life are some of the advantages of using multidisciplinary teams. To be effective, a multidisciplinary team should be equipped with the appropriate tools for diagnosis and follow-up, and at a minimum the multidisciplinary team should include a dermatologist, gastroenterologist and rheumatologist; providing psychologic support via a psychologist and involving an ophthalmologist, general practitioners and nurses in multidisciplinary care is also important.

Conclusion

The present Delphi consensus identified a set of overarching principles that may be useful for implementation of a multidisciplinary approach for the management of SpA-related IMIDs.

Funding

Aristea and Hippocrates.

Psychosocial Distress of Patients with Psoriasis: Protocol for an Assessment of Care Needs and the Development of a Supportive Intervention

BACKGROUND

Psoriasis is a chronic inflammatory disease that is often associated with a number of somatic and mental comorbidity. Patients with psoriasis show an increased risk of depression and (social) anxiety.

OBJECTIVE

The aims of this study are 1) to explore the psychosocial distress of patients with psoriasis and to assess their care needs; and 2) to develop a supportive intervention based on the prior results.

METHODS

A multi-stage design with four phases combining quantitative and qualitative methodology will be used and conducted in two centers. 1) A scoping review and focus groups will be used to design a questionnaire to assess the psychosocial distress and care needs of the patients. 2) The questionnaire developed in phase 1 will be used in a cross-sectional survey to assess the extent of psychosocial distress and supportive care needs in 400 patients with psoriasis. 3) A systematic review and meta-analysis will be conducted to identify psychosocial and psychoeducational interventions for patients with psoriasis and to describe their effectiveness. 4) Based on the results of the phases 2 and 3 a manualized supportive intervention will be developed and the feasibility and acceptance of the intervention will be assessed.

RESULTS

Currently, phase 1 of the project has been completed and the recruitment for phase 2 has been started. The systematic review and meta-analysis of phase 3 are conducted simultaneously to phase 2 and results are expected soon. Phase 4 has not been started yet.

CONCLUSIONS

The expected results of this study will show the extent of psychosocial distress of patients with psoriasis in Germany and supplement previous research with findings about the supportive care needs of this patient group. Moreover, the developed intervention will help to address the psychosocial support needs of patients with psoriasis. Research shows that psychosocial support is strongly needed.

Clinic-based Group Multi-professional Education Causes Significant Decline in Psoriasis Severity: A Randomized Open Label Pilot Study

Background:

The evidence for efficacy of psychoeducational interventions in psoriasis is not well researched.

Objective:

The objective of this study was to assess the benefits of a group, multi-professional, psychoeducational training in psoriasis.

Materials and Methods:

Adults with moderate-to-severe psoriasis were randomized into psychoeducational intervention plus treatment (intervention arm [IA]) and treatment as usual alone (control arm [CA]) groups using random number tables. The primary efficacy measures were mean changes in Psoriasis Area Severity Index (PASI) and Dermatology Life Quality Index (DLQI) at 6months from the end of intervention. The secondary efficacy measures were the mean changes in the WHO-5 well-being index (WHO-5) and the subsets of the patient health questionnaire (PHQ), namely, PHQ-9, generalized anxiety disorder (GAD)-7, andPHQ-15. Datawere analyzed by intention-to-treat analysis.

Results:

One-hundred and three participants were randomized into IA (n = 54) and CA (n = 49). The prevalence of psychiatric disorders in the entire population was 26.2% and was similar in both groups. Following intervention, there was statistically significant improvement in the mean scores in PASI, DLQI, and WHO-5 in the IA unlike that seen in the CA. There was statistically significant improvement in PHQ-9 scores in IA and CA. The scores on PHQ-15 and GAD-7 did not show any change. Intergroup comparisons showed that PASI was reduced significantly in IA as compared to CA. More participants in CA dropped out of the study than in the IA.

Limitations:

Modest sample size and lack of blinding of the participants and the administrators were the limitations of this study.

Conclusion:

Group psychoeducational intervention resulted in overall improvement in both clinical and psychological outcome measures in psoriasis patients.