Psoriasis: 'the badge of shame'. A case report of a psychological intervention to reduce and potentially clear chronic skin disease

Clinical, dermoscopic, and histopathologic evaluation of topical methotrexate 1% hydrogel versus topical Calcipotriol 0.005% cream in the treatment of plaque psoriasis

BACKGROUND

Psoriasis Vulgaris is a common immune-mediated skin disease. Its high prevalence, disability, chronicity, disfiguration, and associated comorbidities make it a challenge for physicians. Topical agents remain the mainstay of treatment for patients with mild to moderate psoriasis.

AIM

To evaluate the efficacy and tolerability of topical methotrexate 1% gel (MTX) versus topical calcipotriol 0.005% cream (CPL) in the treatment of localized plaque psoriasis.

METHODS

This prospective comparative study included 40 patients with localized plaque psoriasis instructed to apply MTX to one side (group A) and CPL to the other side lesions (group B) twice daily for 12 weeks. Clinical and dermoscopic evaluations before, weekly during and after 3 months of treatment were done. The immunohistopathological assessment was done for skin biopsies from 10 patients in each group before and after treatment.

RESULTS

At the end of 12 weeks, there was marked-complete improvement in 97.5% of group A lesions treated with MTX 1% gel compared with 37.5% of group B lesions treated with calcipotriol 0.005% cream (p < 0.001). There was a very high statistically significant improvement in erythema that was cleared totally in 67.5% vs 22.5%, scaling in 75% vs 17.5%, and infiltration in 72.5% vs 27.5% in group A vs B, respectively (p < 0.001). These results were confirmed by dermoscopic and immunohistopathological findings.

CONCLUSION

Methotrexate 1% gel is a marvelous promising well-tolerated effective topical agent that can be used safely in the treatment of localized plaque psoriasis.

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.

Mind-Body Interventions as Alternative and Complementary Therapies for Psoriasis: A Systematic Review of the English Literature

Objective: Conventional therapeutic methods for psoriasis include topical and systemic drugs, phototherapy, and biologic agents. Despite the fact that these treatment methods, and especially biologic agents, are met with a considerable reduction in disease activity, they can sometimes be costly and are nonetheless accompanied by high risks of adverse events, ranging from mild to debilitating. Therefore, complementary and alternative medicine (CAM), especially mind-and-body interventions, such as acupuncture, psychotherapy, climatotherapy, and cupping may provide a cheaper and potentially beneficial outcome for these patients. Methods: We performed a systematic review of articles pertaining to acupuncture, cupping, psychotherapy and meditation, as well climatotherapy and balneotherapy in the management of psoriasis, by using the PubMED, Medline and Google Academic research databases and reference cross-checking. Results: 12 articles on acupuncture, 9 on dry or wet cupping, 27 concerning meditation, hypnosis or psychotherapy, and 34 regarding climate therapy or balneotherapy were found. Discussion and Conclusions: Currently, there is a lack of evidence in the English literature to support acupuncture as an effective alternative therapy for psoriasis, whereas cupping has been described in the majority of instances to result in Koebner phenomenon and clinical worsening. Stress management therapies such as psychotherapy, hypnosis, and meditation have shown promising results as complementary treatment methods. Climatotherapy and balneotherapy have already been proven as effective means of achieving clinical improvement in psoriasis. Further research is still needed to verify the usefulness of the lesser studied treatment methods.

Emotions, Alexithymia, and Emotion Regulation in Patients With Psoriasis

Psoriasis is a chronic dermatological condition that is frequently associated with problematic patterns of emotional reactivity (the way in which patients react to stimuli), alexithymia (their ability to recognize and label the emotional reaction), and emotion regulation (the ability to enhance or reduce their own emotional reaction). A research in the peer-reviewed scientific literature was conducted in order to identify articles describing the association of psoriasis and affective problems. In particular, we first evaluate studies that have investigated abnormal emotional reactivity (in terms of duration, frequency, or type of the experienced emotions) and its impact on patients' quality of life; next, we review the role of alexithymia and emotion regulation in modulating the relationship between emotional reactivity and quality of life in this population. From a critical analysis of the reviewed studies, we highlight that altered emotional processing might be particularly important in the characterization of this condition. In particular, we show that this condition is related to an emotional reactivity characterized by negative emotions that have a stronger impact on patients' quality of life when emotion regulation abilities are weak, especially if patients have alexithymia. Finally, we present suggestions for future directions in both clinical and research fields.

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.