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Psoriasis is a chronic, immune-mediated, inflammatory skin condition that affects approximately 7.4 million adults in the United States. Plaque psoriasis is the most common form of this disease.1 Associated comorbidities include psoriatic arthritis, inflammatory bowel disease, cardiovascular disease, depression, and anxiety.2 Given the unrelenting symptoms and disfiguring nature of plaque psoriasis, patients also suffer from significant, multidimensional psychosocial impairment, leading to decreased quality of life and stress.3

The link between psychological stress and psoriasis is complex, as stress can be both a cause and a consequence of psoriasis exacerbations. Numerous studies have shown that long-term psychological stress is associated with the onset, recurrence, and severity of psoriasis.4,5 In a review of 11 studies evaluating the temporal relationship between stress and psoriasis, 31 to 88 percent of patients cited stress as a trigger for psoriasis, referred to as “stress responders.”4,5 Further support of this relationship was demonstrated in a prospective study that showed that high levels of daily stress predicted an increase of Psoriasis Area and Severity Index (PASI) and itch in the following month.6

The primary mechanism by which stress escalates skin disease and psoriasis is through the hypothalamic-pituitary-adrenal (HPA) axis and cortisol.7 Acute physiologic stress leads to significantly increased cortisol levels in psoriasis patients when compared to patients with rheumatoid arthritis or healthy control patients.8 However, when psoriasis patients who reported being stress responders were subjected to repeated experimental stress, they demonstrated HPA axis dysfunction and lower levels of cortisol than healthy controls.9 This suggests there is a physiological difference between acute and chronic stress on the HPA axis in psoriasis patients. Furthermore, the attenuated HPA activity and blunted cortisol response in “stress-reactive” psoriasis patients may potentially upregulate the pro-inflammatory cytokines present in psoriasis, contributing to the perpetuation of the inflammatory disease state.7 The vicious cycle of psoriatic disease, psychological stress, and resulting exacerbation of disease secondary to this stress adds to the complicated nature of psoriasis management.10

Stress Management

Given the role of stress on psoriatic disease deterioration, stress management is a key therapeutic target in the treatment of psoriasis. Various studies have demonstrated that nonpharmacological interventions, such as relaxation, meditation, cognitive behavioral therapy (CBT), and mindfulness can be used to reduce stress and improve outcomes in patients with psoriasis. A prospective, randomized study compared an eight-week treatment session combining CBT with ultraviolet B (UVB) phototherapy to UVB phototherapy alone.11 This study showed that CBT increased the beneficial effect of UVB phototherapy, with significantly more patients on combined therapy achieving PASI 75 than patients who received phototherapy alone (65 percent vs 15 percent [p=.007]). Patients in the intervention group also reported significantly greater improvements in multiple quality of life and psychiatric measures, including Skindex-29, State/Trait Anxiety Index (STAI), and minor psychiatric disorders (GHQ-12) scores.

In addition to CBT, mindfulness has been shown to be a useful adjunctive therapy for psoriasis. When mindfulness-based cognitive therapy was implemented, psoriasis patients reported significantly reduced psoriatic severity (p=0.05) and improved quality of life (p=0.02) when compared to controls.12 Another randomized, prospective study demonstrated that a brief mindfulness meditation-based stress reduction intervention during ultraviolet light therapy leads to a more rapid resolution of psoriatic lesions when compared to standard ultraviolet light therapy.13

Social Connectedness

In addition to these interventions, social connection and community support groups also play a significant role in stress reduction and clinical improvement in psoriatic patients. Several studies have demonstrated that patients who participate in online support groups have improved health status and health distress.14,15 One study found that psoriasis patients who participated in online communities had improvements in patient-reported outcomes including quality of life, psoriasis severity, and social support.15 Engagement in psoriasis communities, such as the National Psoriasis Foundation and Kopa for Psoriasis, offers patients an outlet to share feelings, discover treatment options, and discuss sensitive topics regarding their disease. Expressive writing about stressful events has also been shown to facilitate coping mechanisms and improve psychological and physical health, which may explain the benefit seen by patients participating in community support groups.16

A Need for Comprehensive Care

The impact of stress on psoriasis highlights the need for comprehensive care, with an emphasis not only on their physical health, but their emotional wellbeing, as well. Studies demonstrating associations between stress and psoriasis severity, as well as nonpharmacological intervention studies demonstrating significant improvements in outcomes when psychological stress is targeted, provide further evidence of the association between mind and skin health. This reinforces the need for physicians and psoriasis patients to work together to integrate psychosocial interventions in long-term therapeutic plans. Additionally, patients who describe their psoriasis as stress responsive may find therapeutic benefits in nonpharmacological interventions such as mindfulness, meditation, CBT, and engagement in psoriasis support communities. Ultimately, physicians should not only strive to improve the patient’s skin but also the patient’s stress and wellbeing.

No funding was provided for the purpose of this report. Dr. Bhutani is an advisor and physician expert for Kopa for Psoriasis. There are no other relevant disclosures.

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