Psychological stress and psoriasis: a systematic review and meta-analysis

Age-standardized incidence, prevalence, and mortality rates of autoimmune diseases in adolescents and young adults (15-39 years): an analysis based on the global burden of disease study 2021

BACKGROUND

Autoimmune diseases (ADs) present significant health challenges globally, especially among adolescents and young adults (AYAs) due to their unique developmental stages. Comprehensive analyses of their burden are limited. This study leverages the Global Burden of Disease (GBD) 2021 data to assess the global, regional, and national burden and trends of major ADs among AYAs from 1990 to 2021.

METHODS

Utilizing data from the Global Burden of Disease (GBD) Study 2021 for individuals aged 15-39 years, we employed a direct method for age standardization to calculate estimates along with 95% uncertainty intervals (UIs) for assessing the age-standardized incidence rates (ASIR), prevalence rates (ASPR), and mortality rates (ASMR) of ADs. The diseases analyzed included rheumatoid arthritis (RA), inflammatory bowel disease (IBD), multiple sclerosis (MS), type 1 diabetes mellitus (T1DM), Asthma, and Psoriasis. Trends from 1990 to 2021 were analyzed using Joinpoint regression, providing average annual percentage changes (AAPC) and 95% confidence intervals (CIs).

RESULT

In 2021, the global ASIR, ASPR, and ASMR of RA among AYAs (per 100,000 population) were 9.46 (95% UI: 5.92 to 13.54), 104.35 (77.44 to 137.84), and 0.016 (0.013 to 0.019), respectively. For IBD, the corresponding rates were 4.08 (3.07 to 5.37), 29.55 (23.00 to 37.83), and 0.10 (0.07 to 0.12). MS exhibited rates of 1.40 (0.93 to 1.93), 16.05 (12.73 to 19.75), and 0.05 (0.04 to 0.05), respectively. T1DM had rates of 6.63 (3.08 to 11.84), 245.51 (194.21 to 307.56), and 0.54 (0.47 to 0.60). Asthma demonstrated rates of 232.22 (132.11 to 361.24), 2245.51 (1671.05 to 2917.57), and 0.89 (0.77 to 1.08). Psoriasis showed rates of 55.08 (48.53 to 61.93) and 426.16 (394.12 to 460.18) for ASIR and ASPR, respectively. From 1990 to 2021, the global ASIR of RA (AAPC = 0.47, 95% CI: 0.46 to 0.49), IBD (0.22 [0.12 to 0.33]), MS (0.22 [0.19 to 0.26]), T1DM (0.83 [0.80 to 0.86]), and Psoriasis (0.33 [0.31 to 0.34]) showed increasing trends, whereas Asthma (-0.96 [-1.03 to -0.88]) showed a decreasing trend. The global ASPR of RA (0.70 [0.68 to 0.73]), MS (0.35 [0.32 to 0.37]), T1DM (0.68 [0.66 to 0.69]), and Psoriasis (0.29 [0.27 to 0.32]) also showed increasing trends, whereas IBD (-0.20 [-0.27 to -0.13]) and Asthma (-1.25 [-1.31 to -1.19]) showed decreasing trends. Notably, the estimated global ASMR of RA (-2.35 [-2.57 to -2.12]), MS (-0.63 [-0.86 to -0.41]), T1DM (-0.35 [-0.56 to -0.14]), and Asthma (-1.35 [-1.44 to -1.26]) in AYAs declined. Additionally, the burden of disease for ADs in AYAs varies considerably across continents and between 204 countries and territories.

CONCLUSION

ADs among AYAs present a substantial public health burden with notable regional disparities in incidence, prevalence, and mortality rates. Understanding these patterns is essential for developing targeted public health interventions and policies to mitigate the impact of ADs in this population.

Prolactin: A Mammalian Stress Hormone and Its Role in Cutaneous Pathophysiology

The hormone prolactin (PRL) is best recognised for its indispensable role in mammalian biology, specifically the regulation of lactation. Bearing in mind that the mammary gland is a modified sweat gland, it is perhaps unsurprising to discover that PRL also plays a significant role in cutaneous biology and is implicated in the pathogenesis of a range of skin diseases, often those reportedly triggered and/or exacerbated by psychological stress. Given that PRL has been implicated in over 300 biological processes, spanning reproduction and hair growth and thermo- to immunoregulation, a comprehensive understanding of the relationship between PRL and the skin remains frustratingly elusive. In an historical curiosity, the first hint that PRL could affect skin biology came from the observation of seborrhoea in patients with post-encephalitic Parkinsonism as a result of another global pandemic, encephalitis lethargica, at the beginning of the last century. As PRL is now being postulated as a potential immunomodulator for COVID-19 infection, it is perhaps timeous to re-examine this pluripotent hormone with cytokine-like properties in the cutaneous context, drawing together our understanding of the role of PRL in skin disease to illustrate how targeting PRL-mediated signalling may represent a novel strategy to treat a range of skin diseases and hair disorders.

Risk Factors for Psoriasis Flares: A Narrative Review

Psoriasis is a chronic inflammatory cutaneous disease with multifactorial pathogenesis involving both genetic and environmental factors as well as the innate and acquired immune response. Several triggering factors may exacerbate or worsen the disease. In this context, we performed a review manuscript with the aim of investigating current literature on psoriasis risk factors, also showing possible mechanisms by which they act on psoriasis. Globally, risk factors can be divided in classic risk factors (eg, mechanical stress, infections and dysbiosis of the skin, common drugs, environment and pollution, lifestyle, psychological stress, hormonal and metabolic alterations) which have long been known to be responsible for worsening and/or reoccurrence of psoriatic manifestations, and emerging risk factors (eg, biological drugs, immunotherapy for oncologic disease, Covid-19, and vaccines) defined as those newly identified risk factors. Accurate patient information and monitoring of risk factors as well as planned follow-ups may help to prevent and treat the worsening of psoriasis and consequently improve the quality of life of psoriatic patients.

Influence of stress resilience in adolescence on long-term risk of psoriasis and psoriatic arthritis among men: A prospective register-based cohort study in Sweden

BACKGROUND

Although stress is considered to be a negative factor for psoriasis, no convincing scientific evidence of this association exists, largely because of difficulties in measuring stress. Stress resilience is the ability to cope with and adapt to stressful events. Stress resilience can be measured in a standardized way and used as a marker for chronic stress.

OBJECTIVES

The objective of this study is to investigate whether low stress resilience in adolescence increases the risk for onset of psoriasis and psoriatic arthritis later in life.

METHODS

A cohort of Swedish men (mean age 18.3 years), enrolled in compulsory military service between 1968 and 2005, was created using data from the Swedish Military Service Conscription Register (n = 1,669,422). Stress resilience at conscription was estimated using standardized semi-structured interviews, and was divided into three categories: low, medium and high. The men were followed from conscription until new-onset psoriasis or psoriatic arthritis, death or emigration or at the latest until 31 December 2019. Cox regression models adjusted for confounders at conscription were used to obtain hazard ratios (HRs) with 95% confidence intervals (CIs) for incident psoriasis and psoriatic arthritis.

RESULTS

Men in the lowest stress resilience category had an increased risk of psoriasis and psoriatic arthritis (HR 1.31 (95% CI 1.26-1.36) and 1.23 (95% CI 1.15-1.32), respectively), compared with those in the highest stress resilience category. When including only hospitalized patients the HRs for psoriasis and psoriatic arthritis in the lowest stress resilience group were 1.79 (1.63-1.98) and 1.53 (1.32-1.77), respectively.

CONCLUSIONS

This large, prospective register study suggests that low stress resilience in adolescence is associated with an increased risk of incident psoriasis among men. The results indicate that patients with psoriasis have an inherent psychological vulnerability, and highlight the importance of addressing psychological well-being in the management of psoriasis.

Inferring skin-brain-skin connections from infodemiology data using dynamic Bayesian networks

The relationship between skin diseases and mental illnesses has been extensively studied using cross-sectional epidemiological data. Typically, such data can only measure association (rather than causation) and include only a subset of the diseases we may be interested in. In this paper, we complement the evidence from such analyses by learning an overarching causal network model over twelve health conditions from the Google Search Trends Symptoms public data set. We learned the causal network model using a dynamic Bayesian network, which can represent both cyclic and acyclic causal relationships, is easy to interpret and accounts for the spatio-temporal trends in the data in a probabilistically rigorous way. The causal network confirms a large number of cyclic relationships between the selected health conditions and the interplay between skin and mental diseases. For acne, we observe a cyclic relationship with anxiety and attention deficit hyperactivity disorder (ADHD) and an indirect relationship with depression through sleep disorders. For dermatitis, we observe directed links to anxiety, depression and sleep disorders and a cyclic relationship with ADHD. We also observe a link between dermatitis and ADHD and a cyclic relationship between acne and ADHD. Furthermore, the network includes several direct connections between sleep disorders and other health conditions, highlighting the impact of the former on the overall health and well-being of the patient. The average R 2 for a condition given the values of all conditions in the previous week is 0.67: in particular, 0.42 for acne, 0.85 for asthma, 0.58 for ADHD, 0.87 for burn, 0.76 for erectile dysfunction, 0.88 for scars, 0.57 for alcohol disorders, 0.57 for anxiety, 0.53 for depression, 0.74 for dermatitis, 0.60 for sleep disorders and 0.66 for obesity. Mapping disease interplay, indirect relationships, and the key role of mediators, such as sleep disorders, will allow healthcare professionals to address disease management holistically and more effectively. Even if we consider all skin and mental diseases jointly, each disease subnetwork is unique, allowing for more targeted interventions.

Triggers for the onset and recurrence of psoriasis: a review and update

Psoriasis is an immune-mediated inflammatory skin disease, involving a complex interplay between genetic and environmental factors. Previous studies have demonstrated that genetic factors play a major role in the pathogenesis of psoriasis. However, non-genetic factors are also necessary to trigger the onset and recurrence of psoriasis in genetically predisposed individuals, which include infections, microbiota dysbiosis of the skin and gut, dysregulated lipid metabolism, dysregulated sex hormones, and mental illness. Psoriasis can also be induced by other environmental triggers, such as skin trauma, unhealthy lifestyles, and medications. Understanding how these triggers play a role in the onset and recurrence of psoriasis provides insights into psoriasis pathogenesis, as well as better clinical administration. In this review, we summarize the triggers for the onset and recurrence of psoriasis and update the current evidence on the underlying mechanism of how these factors elicit the disease. Video Abstract.

Role of stress in skin diseases: A neuroendocrine-immune interaction view

Psychological stress is a crucial factor in the development of many skin diseases, and the stigma caused by skin disorders may further increase the psychological burden, forming a vicious cycle of psychological stress leading to skin diseases. Therefore, understanding the relationship between stress and skin diseases is necessary. The skin, as the vital interface with the external environment, possesses its own complex immune system, and the neuroendocrine system plays a central role in the stress response of the body. Stress-induced alterations in the immune system can also disrupt the delicate balance of immune cells and inflammatory mediators in the skin, leading to immune dysregulation and increased susceptibility to various skin diseases. Stress can also affect the skin barrier function, impair wound healing, and promote the release of pro-inflammatory cytokines, thereby exacerbating existing skin diseases such as psoriasis, atopic dermatitis, acne, and urticaria. In the present review, we explored the intricate relationship between stress and skin diseases from a neuroendocrine-immune interaction perspective. We explored the occurrence and development of skin diseases in the context of stress, the stress models for skin diseases, the impact of stress on skin function and diseases, and relevant epidemiological studies and clinical trials. Understanding the relationship between stress and skin diseases from a neuroendocrine-immune interaction perspective provides a comprehensive framework for targeted interventions and new insights into the diagnosis and treatment of skin diseases.

Chronic stress predisposes to the aggravation of inflammation in autoimmune diseases with focus on rheumatoid arthritis and psoriasis

The global incidence of autoimmune diseases is on the rise, and many healthcare professionals believe that chronic stress plays a prominent role in both the aggravation and remission of these conditions. It is believed that prolonged exposure to stress is associated with neuroimmune axis malfunction, which eventually dysregulates multiple immunological factors as well as deregulates autoimmune responses that play a central role in various autoimmune diseases, including rheumatoid arthritis and psoriasis. Herein, we performed validation of an 8-week long rat model of chronic unpredictable stress (CUS) which consisted of exposing groups of rats to random stressors daily for 8 weeks. Additionally, we developed a novel rat model combining 8-week long random stressor-induced CUS with CIA-triggered arthritis and IMQ-triggered psoriasis and have successfully used both these models to assess the role of chronic stress in the aggravation of arthritis and psoriasis, respectively. Notably, the 8-week CUS protocol extensively aggravated and prolonged both arthritis and psoriasis condition in the rat model by upregulating the release of different pro-inflammatory cytokines, dysregulation of immune cell responses and oxidative stress system, which were all related to severe inflammation. Further, CUS aggravated macroscopic features and the increase in destruction of joint tissue and epidermal thickness induced by CIA and IMQ, respectively, in rats. In conclusion, this study suggests that exposure to an 8-week long CUS paradigm aggravates the distinctive characteristics of rheumatoid arthritis and psoriasis in rats via amplifying the inflammatory circuits and immune cell responses linked to these autoimmune diseases.

Paradoxical psoriasis: The flip side of idiopathic psoriasis or an autocephalous reversible drug reaction?

Psoriasis is a common, chronic skin disease that results mainly from the complex interplay between T cells, dendritic cells, and inflammatory cytokines including TNF-α, IL-17, IL-12, and IL-23. Successful therapy with anti-cytokine antibodies has proved the importance of these key cytokines, especially TNF-α. During the anti-TNF-α treatment of classical idiopathic psoriasis, a small portion of patients develop new psoriasiform lesions. This contradictory phenomenon was named paradoxical psoriasis which resembles idiopathic psoriasis clinically but presents overlapped histological patterns and distinct immunological processes. In this review, we discuss the differences between idiopathic psoriasis and paradoxical psoriasis with an emphasis on their innate immunity, as it is predominant in paradoxical psoriasis which exhibits type I IFN-mediated immunity without the activation of autoreactive T cells and memory T cells. We also put up an instructive algorithm for the management of paradoxical psoriasis. The decision on drug discontinuation or switching of biologics should be made based on the condition of underlying diseases and the severity of lesions.

Assessment of Frontal Hemispherical Lateralization in Plaque Psoriasis and Atopic Dermatitis

BACKGROUND

Each brain hemisphere plays a specialized role in cognitive and behavioral processes, known as hemispheric lateralization. In chronic skin diseases, such as plaque psoriasis (Pso) and atopic dermatitis (AD), the degree of lateralization between the frontal hemispheres may provide insight into specific connections between skin diseases and the psyche. This study aims to analyze the hemispherical lateralization, neurovegetative responses, and psychometric characteristics of patients with Pso and AD.

METHODS

The study included 46 patients with Pso, 56 patients with AD, and 29 healthy control (Ctrl) subjects. The participants underwent frontal electroencephalogram (EEG) measurement, heart rate variability (HRV) assessment, and psychological tests. Statistical analyses were performed using ANOVA, with Bonferroni correction applied for multiple comparisons.

RESULTS

This study shows a significant right-lateralized prefrontal activity in both AD patients (p < 0.001) and Pso patients (p = 0.045) compared with Ctrl, with no significant difference between the AD and Pso groups (p = 0.633). AD patients with right-hemispheric dominant prefrontal activation exhibited increased inhibition and avoidance markers, while Pso patients showed elevated sympathetic nervous system activity.

CONCLUSION

Psychophysiological and psychometric data suggest a shared prevalence of right-hemispheric dominance in both AD and Pso patient groups. However, the findings indicate distinct psychodermatological mechanisms in AD and Pso.

Increased risk of olfactory and taste dysfunction in the United States psoriasis population

BACKGROUND

It is plausible that immunopathological processes associated with psoriasis might contribute to the occurrence of olfactory or taste dysfunction. However, the actual association was still unknown.

PURPOSE

To determine the relationship between olfactory or taste dysfunction and psoriasis.

METHODS

Two cross-sectional studies were performed by using National Health and Nutrition Examination Survey (NHANES) data. Participants with psoriasis were defined as cases and those without psoriasis were identified as controls. Taste and smell self-reported questionnaires were used to define smell/taste alterations and identification tests were used to assure the smell/taste dysfunctions. Logistic regression models with inverse probability treatment weighting (IPTW) strategies were conducted to investigated the relationship between psoriasis and olfactory or taste dysfunction.

RESULTS

Self-reported questionnaires indicated that psoriasis patients were more likely to have perceived taste alteration (IPTW-aOR = 1.43) and smell alteration (IPTW-aOR = 1.22). Identification tests revealed that psoriasis was associated with taste dysfunction (IPTW-aOR = 1.28) and olfactory dysfunction (IPTW-aOR = 1.22). Relevant findings showed that psoriasis may be significantly associated with taste or olfactory dysfunction regardless of the questionnaire data or identification examination data used.

CONCLUSION

Olfactory and taste dysfunction could be considered comorbidities in patients with psoriasis based on our observational study. Therefore, physicians should be cautious of olfaction and taste alterations among patients with psoriasis.

Abnormal functional connectivity in psoriasis patients with depression is associated with their clinical symptoms

Psoriasis is a chronic, autoimmune disorder that is related to mental health disorders such as depression. However, few studies have focused on the features of brain activity in psoriasis patients with depression (PPD) and the association between brain activity and disease severity. A total of 29 PPD and 24 healthy controls were involved in this study, and all participants underwent resting-state functional magnetic resonance imaging (fMRI) scanning. The psoriasis area and severity index (PASI) and the self-rating depression scale (SDS) were used to measure clinical symptoms. Compared with HCs, PPD patients showed increased fractional amplitude of low-frequency fluctuation (fALFF) in the Frontal_Mid_L and increased functional connectivity (FC) between the hypothalamus-R and the Cingulum_Mid_R. Correlation analysis suggested a positive correlation between PASI and SDS scores in PPD, while the fALFF and FC values were negatively correlated with their SDS and PASI scores. These brain regions may be associated with the development of depressive symptoms and disease severity in psoriasis patients.

The impact of perceived stress on the hair follicle: Towards solving a psychoneuroendocrine and neuroimmunological puzzle

While popular belief harbors little doubt that perceived stress can cause hair loss and premature graying, the scientific evidence for this is arguably much thinner. Here, we investigate whether these phenomena are real, and show that the cyclic growth and pigmentation of the hair follicle (HF) provides a tractable model system for dissecting how perceived stress modulates aspects of human physiology. Local production of stress-associated neurohormones and neurotrophins coalesces with neurotransmitters and neuropeptides released from HF-associated sensory and autonomic nerve endings, forming a complex local stress-response system that regulates perifollicular neurogenic inflammation, interacts with the HF microbiome and controls mitochondrial function. This local system integrates into the central stress response systems, allowing the study of systemic stress responses affecting organ function by quantifying stress mediator content of hair. Focusing on selected mediators in this "brain-HF axis" under stress conditions, we distill general principles of HF dysfunction induced by perceived stress.

Epidemiology of Psoriasis and Comorbid Diseases: A Narrative Review

Psoriasis is a chronic autoimmune inflammatory disease that remains active for a long period, even for life in most patients. The impact of psoriasis on health is not only limited to the skin, but also influences multiple systems of the body, even mental health. With the increasing of literature on the association between psoriasis and extracutaneous systems, a better understanding of psoriasis as an autoimmune disease with systemic inflammation is created. Except for cardiometabolic diseases, gastrointestinal diseases, chronic kidney diseases, malignancy, and infections that have received much attention, the association between psoriasis and more systemic diseases, including the skin system, reproductive system, and oral and ocular systems has also been revealed, and mental health diseases draw more attention not just because of the negative mental and mood influence caused by skin lesions, but a common immune-inflammatory mechanism identified of the two systemic diseases. This review summarizes the epidemiological evidence supporting the association between psoriasis and important and/or newly reported systemic diseases in the past 5 years, and may help to comprehensively recognize the comorbidity burden related to psoriasis, further to improve the management of people with psoriasis.

Relationship between Immune Cells, Depression, Stress, and Psoriasis: Could the Use of Natural Products Be Helpful?

Psoriasis is one of the most widespread chronic inflammatory skin diseases, affecting about 2%-3% of the worldwide adult population. The pathogenesis of this disease is quite complex, but an interaction between genetic and environmental factors has been recognized with an essential modulation of inflammatory and immune responses in affected patients. Psoriatic plaques generally represent the clinical psoriatic feature resulting from an abnormal proliferation and differentiation of keratinocytes, which cause dermal hyperplasia, skin infiltration of immune cells, and increased capillarity. Some scientific pieces of evidence have reported that psychological stress may play a key role in psoriasis, and the disease itself may cause stress conditions in patients, thus reproducing a vicious cycle. The present review aims at examining immune cell involvement in psoriasis and the relationship of depression and stress in its pathogenesis and development. In addition, this review contains a focus on the possible use of natural products, thus pointing out their mechanism of action in order to counteract clinical and psychological symptoms.

Calcitonin gene-related peptide upregulates IL-17A and IL-22 in γδ-T cells through the paracrine effect of langerhans cells on LC/γδ-T co-culture model

Intense mental stimulation and stress often directly induce or exacerbate psoriasis. On the contrary, patients with nerve injury and nervous system dysfunction have psoriasis remission. The nervous system plays an important role in the inflammatory process of psoriasis, and neuropeptides are considered as local mediators of disease maintenance. To examine the molecular mechanism involved in this, first we analyzed calcitonin gene-related peptide (CGRP)-treated langerhans Cells and γδ-T cells separately. CGRP induced IL-23 mRNA and protein expression via PDK1-Rsk signaling pathway. However, CGRP had no effect on secretion of IL-17A and IL-22 in γδ-T cells. Then we treated LCs/γδ-T cells Co-culture Model with CGRP. CGRP upregulated IL-17A and IL-22 expression in co-culture model through the paracrine effect of LCs. IL-17A and IL-22 are key cytokines of psoriasis. These findings provide a potential mechanism by which nerve factors affect the development of psoriasis.

Chronic Inflammation as the Underlying Mechanism of the Development of Lung Diseases in Psoriasis: A Systematic Review

Psoriasis is a systemic inflammatory disease caused by dysfunctional interactions between the innate and adaptive immune responses. The systemic inflammation in psoriasis may be associated with the development of comorbidities, including lung diseases. In this review, we aimed to provide a summary of the evidence regarding the prevalence of lung diseases in patients with psoriasis and the potential underlying mechanisms. Twenty-three articles published between March 2010 and June 2021 were selected from 195 initially identified records. The findings are discussed in terms of the prevalence of asthma, chronic obstructive pulmonary disease, interstitial lung disease, obstructive sleep apnea, pulmonary hypertension, and sarcoidosis in psoriasis. A higher prevalence of lung diseases in psoriasis has been confirmed in asthma, chronic obstructive pulmonary disease, obstructive sleep apnea, and pulmonary hypertension. These conditions are important as they are previously unrecognized causes of morbidity and mortality in psoriasis. The development of lung diseases in patients with psoriasis can be explained by several mechanisms, including common risk factors, shared immune and molecular characteristics associated with chronic inflammation, as well as other mechanisms. Understanding the prevalence of lung diseases in psoriasis and their underlying mechanisms can help implement appropriate preventative and therapeutic strategies to address respiratory diseases in patients with psoriasis.

Relevant associations between alexithymia and health-literacy in persons with psoriasis

OBJECTIVE

To explore possible associations between alexithymia and health literacy (HL) in persons with psoriasis.

METHODS

We conducted a cross-sectional study, including 825 persons with moderate to severe psoriasis, using the Toronto Alexithymia Scale, and the Health Literacy Questionnaire. Descriptive statistics compare HL means between alexithymic and not alexithymic participants. Associations between alexithymia and HL are analyzed using a linear multiple regression model.

RESULTS

Twenty-six percent of the participants were characterized as alexithymic, and 26.8% had borderline alexithymia. Higher alexithymia scores were associated with lower education, biological medicines, and more comorbidities, together with lower self-efficacy. The HL domains with the strongest associations with alexithymia were those focusing on managing and getting support for health, as well as the ability to find health information.

CONCLUSION

A more elevated alexithymia score is associated with lower HL. Further studies of these associations may contribute to a more comprehensive perspective of psoriasis. To know a patient's alexithymia level and HL needs may guide health care personnel's understanding of possible associations between health status, clinical presentation, behavior, and response to treatment.

Neurological Complications of Biological Treatment of Psoriasis

In the available literature, little attention has been paid to the assessment of psoriasis and the biological therapy used for it and the nervous system. The purpose of this article is to discuss the relationship between psoriasis and the nervous system as well as to analyze the mechanisms that lead to neurological complications during anticytokine therapies in psoriasis. However, this connection requires further analysis. The use of biological drugs in psoriasis, although it yields positive therapeutic results, is not without numerous side effects. Serious neurological side effects of the therapy are most often visible with the use of anti-TNF-alpha, which is why patients should be monitored for their potential occurrence. Early detection of complications and rapid discontinuation of treatment with the drug may potentially increase the patient’s chances of a full recovery or improvement of his/her neurological condition. It also seems reasonable that, in the case of complications occurring during anti-TNF-alpha therapy, some of the drugs from other groups should be included in the therapy.

New Frontiers in Psoriatic Disease Research, Part II: Comorbidities and Targeted Therapies

Although psoriasis and psoriatic arthritis (PsA) have been classically considered to be diseases of the skin and joints, respectively, emerging evidence suggests that a combination of innate and environmental factors creates widespread immune dysfunction, affecting multiple organ systems. A greater understanding of the pathogenesis of psoriasis and the systemic effects of psoriatic inflammation has allowed for the development of new, more effective treatments. The second portion of this two-part review series examines the comorbidities associated with psoriasis and PsA as well as the most recent advances in targeted systemic therapies for these conditions.

The hair follicle-psoriasis axis: Shared regulatory mechanisms and therapeutic targets

It has long been known that there is a special affinity of psoriasis for the scalp: Here, it occurs most frequently, lesions terminate sharply in frontal skin beyond the hair line and are difficult to treat. Yet, surprisingly, scalp psoriasis only rarely causes alopecia, even though the pilosebaceous unit clearly is affected. Here, we systematically explore the peculiar, insufficiently investigated connection between psoriasis and growing (anagen) terminal scalp hair follicles (HFs), with emphasis on shared regulatory mechanism and therapeutic targets. Interestingly, several drugs and stressors that can trigger/aggravate psoriasis can inhibit hair growth (e.g. beta-blockers, chloroquine, carbamazepine, interferon-alpha, perceived stress). Instead, several anti-psoriatic agents can stimulate hair growth (e.g. cyclosporine, glucocorticoids, dithranol, UV irradiation), while skin/HF trauma (Köbner phenomenon/depilation) favours the development of psoriatic lesions and induces anagen in "quiescent" (telogen) HFs. On this basis, we propose two interconnected working models: (a) the existence of a bidirectional "hair follicle-psoriasis axis," along which keratinocytes of anagen scalp HFs secrete signals that favour the development and maintenance of psoriatic scalp lesions and respond to signals from these lesions, and (b) that anagen induction and psoriatic lesions share molecular "switch-on" mechanisms, which invite pharmacological targeting, once identified. Therefore, we advocate a novel, cross-fertilizing and integrative approach to psoriasis and hair research that systematically characterizes the "HF-psoriasis axis," focused on identification and therapeutic targeting of selected, shared signalling pathways in the future management of both, psoriasis and hair growth disorders.

Risk of psychiatric diseases among patients with psoriasis in Korea: A 12-year nationwide population-based cohort study

The association between psoriasis and risk of psychiatric diseases has not been thoroughly evaluated in a large longitudinal cohort of the Asian population. We conducted a nationwide cohort study encompassing more than 1.6 million Koreans with a 12-year follow-up period. Patients were considered to be in the psoriasis cohort if they had an incident diagnostic code for psoriasis and included patients were followed up until they developed any psychiatric disease. In adjusted models, psoriasis patients (n = 10 868) were at an 18% increased risk for depression (hazard ratio [HR], 1.18; 95% confidence interval [CI], 1.09-1.26), 16% for anxiety disorders (HR, 1.16; 95% CI, 1.08-1.26), and 21% for somatoform disorders (HR, 1.21; 95% CI, 1.08-1.34) compared with the referent cohort (n = 1 620 055). Patients with moderate-to-severe psoriasis had a higher risk of developing depression and somatoform disorders than patient with mild disease (depression, HR, 1.28; 95% CI, 1.07-1.54 vs HR, 1.17; 95% CI, 1.07-1.27; somatoform disorders, HR, 1.60; 95% CI, 1.26-2.03 vs HR, 1.13; 95% CI, 1.00-1.28). Our results highlight the burden of psychiatric diseases in patients with psoriasis in Korea and suggest that appropriate medical support for possible mental illness is warranted in Asian psoriatic patients.

Unconventional Therapy with IgY in a Psoriatic Mouse Model Targeting Gut Microbiome

Psoriasis has a multifactorial pathogenesis and recently it was shown that alterations in the skin and intestinal microbiome are involved in the pathogenesis of psoriasis. Therefore, microbiome restoration becomes a promising preventive/therapy strategy in psoriasis. In our pre-clinical study design using a mice model of induced psoriatic dermatitis (Ps) we have tested the proof-of-concept that IgY raised against pathological human bacteria resistant to antibiotics can alleviate psoriatic lesions and restore deregulated immune cell parameters. Besides clinical evaluation of the mice and histology of the developed psoriatic lesions, cellular immune parameters were monitored. Immune cells populations/subpopulations from peripheral blood and spleen cell suspensions that follow the clinical improvement were assessed using flow cytometry. We have quantified T lymphocytes (CD3ε⁺) with T-helper (CD4⁺CD8^-) and T-suppressor/cytotoxic (CD8a⁺CD4^-) subsets, B lymphocytes (CD3ε^-CD19⁺) and NK cells (CD3ε^-NK1.1⁺). Improved clinical evolution of the induced Ps along with the restoration of immune cells parameters were obtained when orally IgY was administered. We pin-point that IgY specific compound can be used as a possible pre-biotic-like alternative adjuvant in psoriasis.

How stress affects the skin: from designs to mechanisms

Linked Article: Schmidt et al. Br J Dermatol 2021; 185:130–138.

ActiPso: definition of activity types for psoriatic disease: A novel marker for an advanced disease classification

BACKGROUND

Assessment of psoriasis is exclusively done measuring severity using somatic scores such as the psoriasis area and severity index or patient-reported outcomes such as the dermatology life quality index. There is no established tool to measure a patient's individual psoriasis activity over time.

OBJECTIVES

Development of a new tool to classify psoriasis activity types.

METHODS

Open patient interviews were performed and adapted in several steps and by using different groups of patients. Wording of the tool's axis and description how to use it was optimized with the input of patients. The final ActiPso tool was used in a prospective study in psoriasis patients.

RESULTS

Four activity types could be identified describing psoriasis intensity (e.g. severity, itch, pain) over one typical year and an event/trigger type describing flares. In the study in 586 psoriasis patients of the 536 patients eligible for analysis 40.9% self-classified as type 1 ('stable'), 22.6% as type 2 ('unstable'), 30.6% as type 3 ('winter type') and 6.0% as type 4 ('summer type'), respectively. Flares of psoriasis as identified by the event/trigger type were reported in 36.1% of patients with activity type 1, 67.8% with type 2, 73.8% of type 3 and 59.4% of type 4, respectively.

CONCLUSIONS

Interviewed patients were able to describe their course of psoriatic disease and to name potential triggering factors. By doing so, activity types of psoriasis were defined for the first time and the importance of events/triggers for flares described and integrated into ActiPso types as a basis for advanced patient-centric management. A limitation of ActiPso is that in regions with no seasonal variations types 3 and 4 may not apply.

Utilization of health services for skin disorders during military operations. A population- based study

In addition to the immediate casualties of armed conflicts, their indirect impact may bring even more damage by causing malfunctioning of health systems and impaired access to diagnosis and treatment. We conducted a population-based study, to assess the utilization rates of health services due to skin disorders, among civilians exposed to missile attacks and siren alarms during three military operations in Israel. The study was designed as a natural experiment, whereas periods of military operations were compared to the non-military times. During the military operations, when sirens and missiles were an everyday experience, the number of visits to dermatologists was 1.07-1.16 times lower [Relative Risk (RR)=0.86-0.92] as compared to the non-military periods, especially evident for patients residing closer to the military zone, where it dropped almost 2- folds (RR=0.52). Although perceived nonurgent in their majority, the routine care should not be delayed to prevent more serious skin conditions.

Depressive, anxiety, stress, and insomnia symptoms in patients with psoriasis: a cross-sectional study

Introduction

Assessment of psychological well-being in psoriasis patients is recommended. However, studies evaluating depressive, anxiety, stress, and insomnia symptoms in Arabic patients with psoriasis are lacking.

Aim

To quantify levels of psoriasis-related depressive, anxiety, stress, and insomnia symptoms in Arabic patients with psoriasis.

Material and methods

A cross-sectional survey on patients’ demographics, disease characteristics, and psychological measures using the Patient Health Questionnaire-9, Generalized Anxiety Disorder 7-item scale, Depression Anxiety Stress Scale-21 (7-item stress subscale), and Insomnia Severity Index. The prevalence and scores of depressive, anxiety, stress, and insomnia symptoms were calculated. Multivariate linear regression models were developed to assess patients’ demographics and disease characteristics affecting the psychological measures.

Results

The analysis included 223 patients. The patients reported mild levels of depressive, anxiety, and insomnia symptoms (median (interquartile range (IQR)) scores: 9 (6–14), 6 (4–11), and 12 (4–18), respectively) and a moderate level of stress symptoms (median (IQR) score: 10 (5–14)). The prevalence of depressive, anxiety, stress, and insomnia symptoms were 47.1%, 32.7%, 59.6%, and 57%, respectively. Multivariate linear regression analyses revealed that for each unit increase in the impact of psoriasis on daily life, there were 5.7 (95% confidence intervals (CI): 3.7–7.8), 3.8 (95% CI: 1.8–5.7), 5.3 (95% CI: 3.1–7.4), and 6.5 (95% CI: 3.7–9.4) units increase in depression, anxiety, and stress, and insomnia scores, respectively.

Conclusions

The prevalence of depressive, anxiety, stress, and insomnia symptoms in Arabic patients with psoriasis was high. Clinical interventions, screening for psychiatric comorbidities, and consideration of psychotherapy should be implemented in this patient group.

Partner bereavement and risk of psoriasis and atopic eczema: cohort studies in the U.K. and Denmark

BACKGROUND

Stress is commonly cited as a risk factor for psoriasis and atopic eczema, but such evidence is limited.

OBJECTIVES

To investigate the association between partner bereavement (an extreme life stressor) and psoriasis or atopic eczema.

METHODS

We conducted cohort studies using data from the U.K. Clinical Practice Research Datalink (1997-2017) and Danish nationwide registries (1997-2016). The exposed cohort was partners who experienced partner bereavement. The comparison cohort was up to 10 nonbereaved partners, matched to each bereaved partner by age, sex, county of residence (Denmark) and general practice (U.K.). Outcomes were the first recorded diagnosis of psoriasis or atopic eczema. We estimated hazard ratios (HRs) and confidence intervals (CIs) using a stratified Cox proportional hazards model in both settings, which were then pooled in a meta-analysis.

RESULTS

The pooled adjusted HR for the association between bereavement and psoriasis was 1·01 (95% CI 0·98-1·04) across the entire follow-up. Similar results were found in other shorter follow-up periods. Pooled adjusted HRs for the association between bereavement and atopic eczema were 0·97 (95% CI 0·84-1·12) across the entire follow-up, 1·09 (95% CI 0·86-1·38) within 0-30 days, 1·18 (95% CI 1·04-1·35) within 0-90 days, 1·14 (95% CI 1·06-1·22) within 0-365 days and 1·07 (95% CI 1·02-1·12) within 0-1095 days.

CONCLUSIONS

We found a modest increase in the risk of atopic eczema within 3 years following bereavement, which peaked in the first 3 months. Acute stress may play a role in triggering onset of new atopic eczema or relapse of atopic eczema previously in remission. We observed no evidence for increased long-term risk of psoriasis and atopic eczema following bereavement.

Comorbid psoriasis-bipolar disorder successfully treated with apremilast: much more than a mere coincidence?

Psoriasis is a chronic, immune mediated, systemic inflammatory skin disease with a reported prevalence of 0.6%–4.8% in the general population. Bipolar disorder (BP) is a severe episodic psychiatric disorder that ranks as the fourth leading cause of disability. Recent evidence suggests that genetic and immunological factors play a significant role in the development of both disorders. Studies have also shown a higher association of psychiatric disorders among patients with psoriasis. Moreover, several autoimmune comorbidities have been reported in association with BP. Here, we describe a young woman with BP who developed psoriasis after 1 year of developing BP and showed exacerbations in psoriasis lesions with each manic episode. We also highlight the safe and efficacious use of apremilast for psoriatic lesions in the woman.

Combination of targeted UVB phototherapy and calcipotriene versus targeted UVB alone in psoriasis: systematic review and meta-analysis of randomized controlled trials

Background: Targeted UVB and topical calcipotriene have frequently been used in the treatment of psoriasis, but the joint effect of calcipotriene and targeted UVB has been controversial.Objectives: The purpose of this study was to systematically evaluate whether the efficacy of the combined use of targeted UVB and calcipotriene is superior to the targeted UVB alone.Methods: We performed systematic review and meta-analysis of randomized controlled trials (RCTs) in patients with plaque-type psoriasis through searching the defined key words in the PubMed, EMBase, and Cochrane Central Register databases. Pooled mean difference of the Psoriasis Area and Severity Index (PASI) relative change (%) was estimated using a random effect model. The quality of included studies and publication bias were assessed using the Jadad scale and the Egger's test, respectively.Results: A total of five RCTs including 182 patients were included in the systematic review. The mean difference of the PASI relative change (%) between the combined therapy versus the targeted UVB alone was -22.68 (95%CI: -37.12 to -8.24; p = .002). Publication bias was not supported by the Egger's test (p = .424).Conclusion: Addition of calcipotriene ointment may improve the efficacy of the targeted UVB phototherapy in the treatment of plaque-type psoriasis.

Association between IL28B Polymorphisms and Outcomes of Hepatitis B Virus Infection: A meta-analysis

BACKGROUND

Interleukin (IL) 28B polymorphisms encoding pro-inflammatory and anti-inflammatory cytokines trigger diverse clinical outcome of hepatitis virus infection. However, there is controversy concerning the association of IL28B polymorphisms with the outcome of hepatitis B virus (HBV) infection, with several studies obtaining inconsistent results. We performed a meta-analysis to evaluate the role of 3 single nucleotide polymorphisms (SNPs) rs12979860, rs12980275 and rs8099917 in the progression of HBV infection, overall and by ethnicity.

METHODS

Searched PubMed, Embase and Wiley Online Library electronic databases using 'interleukin 28B', 'IL 28B', 'IL 28B polymorphism', 'hepatitis B virus', 'HBV', and performed meta- analysis for rs12979860, rs12980275 and rs8099917 in Asian and Caucasian populations under the dominant recessive and allele model.

RESULTS

Eighteen studies were found in total and used for this meta-analysis, including 5587 cases and 4295 controls. The IL28B polymorphism rs12979860 had no association with HBV persistence (CC vs CT + TT: OR = 0.86, 95% CI = 0.76-1.00; TT vs CT + CC: OR = 1.14, 95% CI = 0.76-1.70; T vs C: OR = 1.03, 95% CI = 0.94-1.13). Similarly, neither rs12980275 nor rs8099917 had associations with HBV persistence (rs12980275 in AA vs AG + AA: OR = 1.15, 95% CI = 0.96-1.38; rs8099917 in TT vs GT + GG: OR = 1.15, 95% CI = 0.96-1.39). There was also no significant association of IL28B polymorphisms with persistent HBV infection in Asians or Chinese. There was no evidence of an association of rs12979860 with the HBV-related hepatocellular carcinoma susceptibility (T vs C: OR = 1.53, 95% CI = 0.96-2.43).

CONCLUSION

IL28B polymorphisms had no association with the outcome of HBV infection overall, nor in the Asians and the Chinese. These 3 SNPs might not be relevant to the development of HBV infection.

Extra-adrenal glucocorticoid biosynthesis: implications for autoimmune and inflammatory disorders

Glucocorticoid synthesis is a complex, multistep process that starts with cholesterol being delivered to the inner membrane of mitochondria by StAR and StAR-related proteins. Here its side chain is cleaved by CYP11A1 producing pregnenolone. Pregnenolone is converted to cortisol by the enzymes 3-βHSD, CYP17A1, CYP21A2 and CYP11B1. Glucocorticoids play a critical role in the regulation of the immune system and exert their action through the glucocorticoid receptor (GR). Although corticosteroids are primarily produced in the adrenal gland, they can also be produced in a number of extra-adrenal tissue including the immune system, skin, brain, and intestine. Glucocorticoid production is regulated by ACTH, CRH, and cytokines such as IL-1, IL-6 and TNFα. The bioavailability of cortisol is also dependent on its interconversion to cortisone which is inactive, by 11βHSD1/2. Local and systemic glucocorticoid biosynthesis can be stimulated by ultraviolet B, explaining its immunosuppressive activity. In this review, we want to emphasize that dysregulation of extra-adrenal glucocorticoid production can play a key role in a variety of autoimmune diseases including multiple sclerosis (MS), lupus erythematosus (LE), rheumatoid arthritis (RA), and skin inflammatory disorders such as psoriasis and atopic dermatitis (AD). Further research on local glucocorticoid production and its bioavailability may open doors into new therapies for autoimmune diseases.

The association between chronic psychological stress and uterine fibroids risk: A meta-analysis of observational studies

The association between chronic psychological stress and uterine fibroids (UFs) risk remains unclear. In this study, a meta-analysis of observational studies was performed to explore the reported association between them. A literature search was performed in PubMed, EMBASE, and Web of Science to identify relevant published articles. A random-effect model was used to examine pooled odds ratio (OR) and 95% confidence interval (CI). Additionally, subgroup analyses and two-stage random-effect dose-response meta-analysis were performed. A total of six articles with seven studies were included in this meta-analysis. For the highest versus lowest category of chronic psychological stress, the pooled OR was 1.24 (95% CI [1.15, 1.34]; p = .000). Through subgroup analyses, we found a positive association between chronic psychological stress and UFs risk especially in non-Hispanic Blacks studies (OR, 1.24, 95% CI [1.14, 1.34], p = .000). When evaluating for a dose-response, we found a weak correlation between chronic psychological stress and UFs risk, especially for the severe (OR, 1.17, 95% CI [1.07, 1.29]) and very severe (OR, 1.23, 95% CI [1.07, 1.41]) categories. Our meta-analysis shows a statistically significant association between chronic psychological stress and UFs risk particularly for non-Hispanic Blacks. Interventions aiming to reduce chronic psychological stress may be useful to decrease the prevalence of UFs.

Psychological stress levels in women with endometriosis: systematic review and meta-analysis of observational studies

INTRODUCTION

Endometriosis is defined as the presence of endometrial-like tissue outside the uterus, associated with chronic and inflammatory reaction. Symptoms range from dysmenorrhea, dyspareunia, chronic pelvic pain, unexplained infertility to asymptomatic. The patients' quality of life is affected by anxiety, depression and stress. We aimed to verify the prevalence and levels of psychological stress among women with endometriosis.

EVIDENCE ACQUISITION

The systematic review followed the PRISMA statement and the MOOSE guideline. Databases searched were MEDLINE, EMBASE, PsychNET and SciELO. The risk of bias was assessed with a modified Newcastle-Ottawa Scale. The meta-analysis of proportions used inverse variance method for pooling and random-effects model. For the stress levels we used the restricted maximum likelihood estimator for summary effects. Heterogeneity was assessed through I2 and Q statistics. Publication bias was assessed through funnel plots. Meta-regression adopted a mixed-effects model, considering patient age, endometriosis staging, stress assessment tool and data collection as categorical moderators.

EVIDENCE SYNTHESIS

We included 15 studies encompassing 4,619 women with endometriosis. The overall prevalence of mild/high stress was 68% (95%CI:57%-79%), I2=98% and τ2=0.0228. The mean level of stress was 41.78% (95%CI =34.05%-49.51%), I2=99.9% and τ2=83.35. Meta-regression showed relationship with endometriosis staging.

CONCLUSIONS

This is the first meta-analysis exploring the association between endometriosis and psychological stress. The interdisciplinary management of the disease should expand the mental health support in this patient care, beyond pain management. Finally, the attitude of the medical team acknowledging the patients' psychological stress may positively affect their treatment.

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.

Risk Factors for the Development of Psoriasis

Psoriasis is an immune-mediated genetic skin disease. The underlying pathomechanisms involve complex interaction between the innate and adaptive immune system. T cells interact with dendritic cells, macrophages, and keratinocytes, which can be mediated by their secreted cytokines. In the past decade, biologics targeting tumor necrosis factor-α, interleukin (IL)-23, and IL-17 have been developed and approved for the treatment of psoriasis. These biologics have dramatically changed the treatment and management of psoriasis. In contrast, various triggering factors can elicit the disease in genetically predisposed individuals. Recent studies suggest that the exacerbation of psoriasis can lead to systemic inflammation and cardiovascular comorbidity. In addition, psoriasis may be associated with other auto-inflammatory and auto-immune diseases. In this review, we summarize the risk factors, which can be divided into two groups (namely, extrinsic and intrinsic risk factors), responsible for the onset and exacerbation of psoriasis in order to facilitate its prevention.

Perceived stress, life events, fatigue and temperament in patients with psoriasis

Objective

To evaluate the perceived stress, life events, fatigue and temperament profile in patients with psoriasis and to investigate the relationship between these factors.

Methods

This cross-sectional study included patients with psoriasis and healthy control subjects. The two groups were compared regarding the number of life events, Perceived Stress Scale (PSS) and Multidimensional Assessment of Fatigue scores. The Temperament Evaluation of Memphis, Pisa, Paris and San Diego Autoquestionnaire was used to evaluate the personality traits among the two groups.

Results

A total of 75 patients with psoriasis (mean ± SD age, 44.94 ± 13.62 years) and 75 healthy controls (mean ± SD age, 41.10 ± 8.89 years) were included in the study. A statistically significant difference was found between the two groups in terms of the presence of life events, PSS score, fatigue and temperament profiles. Patients with psoriasis with depressive, cyclothymic and anxious temperament profiles were found to have higher PSS scores. In the psoriasis group, the PSS scores were positively correlated with the number of life events.

Conclusions

Stress and life events were found to be correlated with psoriasis. In the patients with psoriasis, depressive, cyclothymic and anxious temperament profiles seemed to be associated with higher perceived stress.

The efficacy of psychological interventions on psoriasis treatment: a systematic review and meta-analysis of randomized controlled trials

Background

Previous observational studies have shown comorbidity between psoriasis and psychological disorders. However, the evidence of the efficacy of psychological interventions, including cognitive behavioral therapy (CBT) and other treatments, on psoriasis is still debated.

Objectives

The aim of this study was to systematically review the psychological interventions used in the treatment of psoriasis and to meta-analyze the efficacy of psychological interventions on psoriasis with respect to area and severity reduction.

Materials and methods

A systematic review and meta-analysis were conducted. PubMed, Web of Science, EMbase, and major Chinese academic journal databases were searched for articles published before January 2018. Studies of randomized controlled trials (RCTs) that applied psychological interventions in the treatment of psoriasis and used area and severity as the outcome measures were meta-analyzed. The pooled mean difference between groups was estimated using either fixed-effects models or random-effects models in the presence of heterogeneity. Subgroup analysis was performed by method of intervention and severity of psoriasis.

Results

Out of the 4,152 potentially relevant studies, 8 RCTs were included. The pooled mean difference was −1.36 (95% CI: −2.52 to −0.19; P=0.02). The pooled estimate was −1.80 (95% CI: −2.57 to −1.03; P<0.001) for CBT intervention and was −0.70 (95% CI: −2.39 to 0.99; P=0.42) for non-CBT intervention. The pooled estimates for mild and moderate-to-severe psoriasis were −1.95 (95% CI: −3.91 to 0.00; P=0.05) and −0.61 (95% CI: −1.61 to 0.38; P=0.23), respectively.

Conclusion

CBT is effective in the treatment of psoriasis in terms of area and severity reduction. Systemic treatment does not further enhance the efficacy of CBT. The effect of the psychological intervention is stronger in patients with moderate-to-severe psoriasis.

A Controlled Study of the Feasibility and Efficacy of a Cloud-Based Interactive Management Program Between Patients with Psoriasis and Physicians

BACKGROUND Dermatology patients continue to receive improved treatment, but for patients with psoriasis, there have been few studies on ways to improve patient management by improving communication with patients and their dermatologists. This study aimed to investigate the feasibility and efficacy of cloud-based interactive patient and physician management of psoriasis. MATERIAL AND METHODS The cloud-based platform was created by professional software engineers to educate and manage patients with psoriasis in a single hospital, where patients and research staff had a network platform for sharing data. A total of 79 patients with psoriasis were included in this study and were randomly divided into the control group (n=39) and the intervention group (n=40). Patients in the control group were given a psoriasis nursing manual and underwent regular follow-up. Patients in the intervention group were managed using the cloud platform, with the same management as the control group. The Psoriasis Area Severity Index (PASI), the Self-Rating Anxiety Scale (SAS), the Dermatology Life Quality Index (DLQI), and the Symptom Checklist-90-Revised (SCL-90-R) were used. RESULTS Cloud-based interactive patient and physician management resulted in clinical improvement, and reduced the degree of anxiety in patients with psoriasis and improved their physical and mental health. Patients in the intervention group had an improved understanding of psoriasis treatment, resulting in an improved relationship with the medical staff and improved treatment compliance. CONCLUSIONS Cloud-based interactive patient and physician management improved the mental health and quality of life for patients with psoriasis and allowed patients to manage their disease more effectively.