Skip to main content

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

Abstract

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.

This is a preview of subscription content, access via your institution.

Fig. 1

References

  1. Rachakonda TD, Schupp CW, Armstrong AW. Psoriasis prevalence among adults in the United States. J Am Acad Dermatol. 2014;70:512–6.

    Article  PubMed  Google Scholar 

  2. Gelfand JM, Neimann AL, Shin DB, Wang X, Margolis DJ, Troxel AB. Risk of myocardial infarction in patients with psoriasis. JAMA. 2006;296:1735.

    CAS  Article  PubMed  Google Scholar 

  3. Manolache L, Petrescu-Seceleanu D, Benea V. Life events involvement in psoriasis onset/recurrence. Int J Dermatol. 2010;49:636–41.

    Article  PubMed  Google Scholar 

  4. Verhoeven EWM, Kraaimaat FW, De Jong EMGJ, Schalkwijk J, Van De Kerkhof PCM, Evers AWM. Individual differences in the effect of daily stressors on psoriasis: a prospective study. Br J Dermatol. 2009;161:295–9 (Elsevier Masson SAS).

    CAS  Article  PubMed  Google Scholar 

  5. Fortune DG, Richards HL, Kirby B, McElhone K, Markham T, Rogers S, et al. Psychological distress impairs clearance of psoriasis in patients treated with photochemotherapy. Arch Dermatol. 2003;139:752–6.

    Article  PubMed  Google Scholar 

  6. Pompili M, Snast I, Reiter O, Atzmony L, Leshem YA, Hodak E, Mimouni D, et al. P stress and psoriasis: a systematic review and meta-analysis. BJD. 2018;178:1044–55.

    Article  Google Scholar 

  7. Snast I, Reiter O, Atzmony L, Leshem YA, Hodak E, Mimouni D, et al. Psychological stress and psoriasis: a systematic review and meta-analysis. Br J Dermatol. 2018;178:1044–55.

    CAS  Article  PubMed  Google Scholar 

  8. Stewart TJ, Tong W, Whitfeld MJ. The associations between psychological stress and psoriasis: a systematic review. Int J Dermatol. 2018;57:1275–82.

    Article  PubMed  Google Scholar 

  9. Dalgard FJ, Gieler U, Tomas-Aragones L, Lien L, Poot F, Jemec GBE, et al. The psychological burden of skin diseases: a cross-sectional multicenter study among dermatological out-patients in 13 European countries. J Investig Dermatol. 2015;135:984–91.

    CAS  Article  PubMed  Google Scholar 

  10. Lewinson RT, Vallerand IA, Lowerison MW, Parsons LM, Frolkis AD, Kaplan GG, et al. Depression is associated with an increased risk of psoriatic arthritis among patients with psoriasis: a population-based study. J Investig Dermatol. 2017;137:828–35 (the authors).

    CAS  Article  PubMed  Google Scholar 

  11. Nerurkar L, Siebert S, McInnes IB, Cavanagh J. Rheumatoid arthritis and depression: an inflammatory perspective. Lancet Psychiatry. 2018;6:164–73.

    Article  PubMed  Google Scholar 

  12. Piaserico S, Marinello E, Dessi A, Linder MD, Coccarielli D, Peserico A. Efficacy of biofeedback and cognitive-behavioural therapy in psoriatic patients: a single-blind, randomized and controlled study with added narrow-band ultraviolet B therapy. Acta Derm Venereol. 2016;96:91–5.

    Article  PubMed  Google Scholar 

  13. Fordham B, Griffiths CEM, Bundy C. A pilot study examining mindfulness-based cognitive therapy in psoriasis. Psychol Health Med. 2015;20:121–7.

    CAS  Article  PubMed  Google Scholar 

  14. Lambert J, Bostoen J, Geusens B, Bourgois J, Boone J, De Smedt D, et al. A novel multidisciplinary educational programme for patients with chronic skin diseases: ghent pilot project and first results. Arch Dermatol Res. 2011;303:57–63.

    CAS  Article  PubMed  Google Scholar 

  15. Fortune DG, Richards HL, Kirby B, Bowcock S, Main CJ, Griffiths CEM. A cognitive-behavioural symptom management programme as an adjunct in psoriasis therapy. Br J Dermatol. 2002;146:458–65.

    CAS  Article  PubMed  Google Scholar 

  16. Kabat-Zinn J, Wheeler E, Light T, Skillings A, Scharf MJ, Cropley TG, et al. Influence of a mindfulness meditation-based stress reduction intervention on rates of skin clearing in patients with moderate to severe psoriasis undergoing photo therapy (UVB) and photochemotherapy (PUVA). Psychosom Med. 1998;60:625–32.

    CAS  Article  PubMed  Google Scholar 

  17. Zachariae R, Øster H, Bjerring P, Kragballe K. Effects of psychologic intervention on psoriasis: a preliminary report. J Am Acad Dermatol. 1996;34:1008–15.

    CAS  Article  PubMed  Google Scholar 

  18. Gaston L, Crombez JC, Lassonde M, Bernier-Buzzanga J, Hodgins S. Psychological stress and psoriasis: experimental and prospective correlational studies. Acta Dermato Venereol Suppl. 1991;156:37–43.

    CAS  Google Scholar 

  19. Linder D, Dall’olio E, Gisondi P, Berardesca E, De Gennaro E, Pennella AR, et al. Perception of disease and doctor-patient relationship experienced by patients with psoriasis: a questionnaire-based study. Am J Clin Dermatol. 2009;10:325–30.

    Article  PubMed  Google Scholar 

  20. Hawro T, Maurer M, Hawro M, Kaszuba A, Cierpiałkowska L, Królikowska M, et al. In psoriasis, levels of hope and quality of life are linked. Arch Dermatol Res. 2014;306:661–6.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Chen Y, Xin T, Cheng ASK. Evaluating the effectiveness of psychological and/or educational interventions in psoriasis: a narrative review. J Dermatol. 2014;41:775–8.

    Article  PubMed  Google Scholar 

  22. Fordham B, Griffiths CEM, Bundy C. Can stress reduction interventions improve psoriasis? A review. Psychol Health Med. 2013;18:501–14.

    Article  PubMed  Google Scholar 

  23. Harbour R, Miller J. A new system for grading recommendations in evidence based guidelines. BMJ. 2001;323:334–6 (BMJ Publishing Group).

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  24. Hayes SC, Villatte M, Levin M, Hildebrandt M. Open, aware, and active: contextual approaches as an emerging trend in the behavioral and cognitive therapies. Annu Rev Clin Psychol. 2011;7:141–68.

    Article  PubMed  Google Scholar 

  25. Van Beugen S, Ferwerda M, Hoeve D, Rovers MM, Spillekom-Van Koulil S, Van Middendorp H, et al. Internet-based cognitive behavioral therapy for patients with chronic somatic conditions: a meta-analytic review. J Med Internet Res. 2014;16(3):e88.

    Article  PubMed  PubMed Central  Google Scholar 

  26. van Beugen S, Ferwerda M, Spillekom-van Koulil S, Smit JV, Zeeuwen-Franssen MEJ, Kroft EBM, et al. Tailored therapist-guided internet-based cognitive behavioral treatment for psoriasis: a randomized controlled trial. Psychother Psychosom. 2016;85:297–307.

    Article  PubMed  Google Scholar 

  27. Bundy C, Pinder B, Bucci S, Reeves D, Griffiths CEM, Tarrier N. A novel, web-based, psychological intervention for people with psoriasis: the electronic targeted intervention for psoriasis (eTIPs) study. Br J Dermatol. 2013;169:329–36.

    CAS  Article  PubMed  Google Scholar 

  28. Shah R, Bewley A. Psoriasis: “The badge of shame”. A case report of a psychological intervention to reduce and potentially clear chronic skin disease. Clin Exp Dermatol. 2014;39:600–3.

    CAS  Article  PubMed  Google Scholar 

  29. Koulil SS, Ferwerda M, van Beugen S, van Middendorp HT, van de Kerkhof PCM, An Riel PLCM, et al. Tailored therapist-guided internet-based cognitive-behavioural treatment for psoriasis and rheumatoid arthritis: two case reports. Acta Derm Venereol. 2018;98(2):225–33.

    Article  PubMed  Google Scholar 

  30. Fortune DG, Richards HL, Griffiths CEM, Main CJ. Targeting cognitive-behaviour therapy to patients’ implicit model of psoriasis: results from a patient preference controlled trial. Br J Clin Psychol. 2004;43:65–82.

    Article  PubMed  Google Scholar 

  31. Price ML, Mottahedin I, Mayo PR. Can psychotherapy help patients with psoriasis? Clin Exp Dermatol. 1991;16:114–7.

    CAS  Article  PubMed  Google Scholar 

  32. Zachariae R, Bjerring P, Arendt-Nielsen L. Modulation of Type I immediate and Type IV delayed immunoreactivity using direct suggestion and guided imagery during hypnosis. Allergy. 1989;44:537–42.

    CAS  Article  PubMed  Google Scholar 

  33. Zachariae R, Bjerring P. The effect of hypnotically induced analgesia on flare reaction of the cutaneous histamine prick test. Arch Dermatol Res. 1990;282:539–43.

    CAS  Article  PubMed  Google Scholar 

  34. Frank DL, Khorshid L, Kiffer JF, Moravec CS, McKee MG. Biofeedback in medicine: who, when, why and how? Ment Health Fam Med. 2010;7:85–91.

    PubMed  PubMed Central  Google Scholar 

  35. Goodman M. An hypothesis explaining the successful treatment of psoriasis with thermal biofeedback: a case report. Biofeedback Self Regul. 1994;19(4):347–52.

    CAS  Article  PubMed  Google Scholar 

  36. Keinan G, Segal A, Gal U, Brenner S. Stress management for psoriasis patients: the effectiveness of biofeedback and relaxation techniques. Stress Med. 1995;11:235–41.

    Article  Google Scholar 

  37. Gotink RA, Chu P, Busschbach JJV, Benson H, Fricchione GL, Hunink MGM. Standardised mindfulness-based interventions in healthcare: an overview of systematic reviews and meta-analyses of RCTs. PLoS One. 2015;10:e0124344.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Häuser W, Hagl M, Schmierer A, Hansen E. The efficacy, safety and applications of medical hypnosis. Dtsch Arztebl Int. 2016;113:289–96.

    PubMed  PubMed Central  Google Scholar 

  39. Boncz I, Farkas B, Hunyadi J. Experiences with group hypnotherapy of psoriatic patients. Aust J Clin Hypnother Hypn. 1990;11:15–20.

    Google Scholar 

  40. Tausk F, Whitmore E. A pilot study of hypnosis in the treatment of patients with psoriasis. Psychother Psychosom. 1999;68:221–5.

    CAS  Article  PubMed  Google Scholar 

  41. Lazaroff I, Shimshoni R. Effects of medical resonance therapy music on patients with psoriasis and neurodermatitis—a pilot study. Integr Physiol Behav Sci. 2000;35:189–98.

    CAS  Article  PubMed  Google Scholar 

  42. Larsen MH, Krogstad AL, Aas E, Moum T, Wahl AK. A telephone-based motivational interviewing intervention has positive effects on psoriasis severity and self-management: a randomized controlled trial. Br J Dermatol. 2014;171(6):1458–69.

    CAS  Article  PubMed  Google Scholar 

  43. Paradisi A, Abeni D, Finore E, Di Pietro C, Sampogna F, Mazzanti C, et al. Effect of written emotional disclosure interventions in persons with psoriasis undergoing narrow band ultraviolet B phototherapy. Eur J Dermatol. 2010;20:599–605.

    PubMed  Google Scholar 

  44. Tabolli S, Naldi L, Pagliarello C, Sampogna F, Di Pietro C, Spagnoli A, et al. Evaluation of the impact of writing exercises interventions on quality of life in patients with psoriasis undergoing systemic treatments. Br J Dermatol. 2012;167:1254–64.

    CAS  Article  PubMed  Google Scholar 

  45. Vedhara K, Morris RM, Booth R, Horgan M, Lawrence M, Birchall N. Changes in mood predict disease activity and quality of life in patients with psoriasis following emotional disclosure. J Psychosom Res. 2007;62:611–9.

    Article  PubMed  Google Scholar 

  46. Singh SM, Narang T, Vinay K, Sharma A, Satapathy A, Handa S, et al. Clinic-based group multi-professional education causes significant decline in psoriasis severity: a randomized open label pilot study. Indian Dermatol Online J. 2017;8:454–9.

    Article  PubMed  PubMed Central  Google Scholar 

  47. Van Geel MJ, Spillekom-Van Koulil S, Oostveen AM, Van De Kerkhof PCM, Klompmaker-Van Den Hoek W, Teunissen M, et al. An outpatient multidisciplinary training programme for children and adolescents with psoriasis and their parents: a pilot study. Eur J Dermatol. 2016;26:393–5.

    PubMed  Google Scholar 

  48. Schmitt J, Wozel G, Garzarolli M, Viehweg A, Bauer M, Leopold K. Effectiveness of interdisciplinary vs. dermatological care of moderate-to-severe psoriasis: a pragmatic randomised controlled trial. Acta Derm Venereol. 2014;94:192–7.

    Article  PubMed  Google Scholar 

  49. Balato N, Megna M, Di Costanzo L, Balato A, Ayala F. Educational and motivational support service: a pilot study for mobile-phone-based interventions in patients with psoriasis. Br J Dermatol. 2013;168:201–5.

    CAS  Article  PubMed  Google Scholar 

  50. Bostoen J, Bracke S, De Keyser S, Lambert J. An educational programme for patients with psoriasis and atopic dermatitis: a prospective randomized controlled trial. Br J Dermatol. 2012;167:1025–31.

    CAS  Article  PubMed  Google Scholar 

  51. Ersser SJ, Cowdell FC, Nicholls PG, Latter SM, Healy E. A pilot randomized controlled trial to examine the feasibility and efficacy of an educational nursing intervention to improve self-management practices in patients with mild-moderate psoriasis. J Eur Acad Dermatol Venereol. 2012;26:738–45.

    CAS  Article  PubMed  Google Scholar 

  52. Lora V, Gisondi P, Calza A, Zanoni M, Girolomoni G. Efficacy of a single educative intervention in patients with chronic plaque psoriasis. Dermatology. 2009;219:316–21.

    Article  PubMed  Google Scholar 

  53. Svendsen MT, Andersen F, Hansen J, Johannessen H, Andersen KE. Medical adherence to topical corticosteroid preparations prescribed for psoriasis: a systematic review. J Dermatol Treat. 2017;28:32–9.

    CAS  Article  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Alison Ehrlich.

Ethics declarations

Funding

No sources of funding were used to conduct this study or prepare this manuscript.

Conflict of interest

Olabola Awosika has received fellowship support from Janssen Pharmaceuticals and has no conflicts of interest that are directly relevant to the content of this article. Azam A. Qureshi, Francesca Baruffi, Monica Rengifo-Pardo, and Alison Ehrlich have no conflicts of interest that are directly relevant to the content of this article.s

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (PDF 60 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Qureshi, A.A., Awosika, O., Baruffi, F. et al. Psychological Therapies in Management of Psoriatic Skin Disease: A Systematic Review. Am J Clin Dermatol 20, 607–624 (2019). https://doi.org/10.1007/s40257-019-00437-7

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40257-019-00437-7