Psychosocial Burden and Psychological Interventions for Patients with Psoriasis

Abstract

Characterized by pruritic, scaly plaques, psoriasis is an immune-mediated chronic cutaneous condition associated with a negative impact on quality of life. In addition, psoriatic patients exhibit a greater incidence of anxiety and depression compared to the general population. The relationship between psoriasis and mental health has been shown to be bidirectional with disease activity worsening psychological burden, and psychological burden conversely impacting disease activity. While few studies to our knowledge precisely delineate the proportion of psoriatic patients with untreated mental health concerns, literature suggests many patients are not receiving optimal or timely mental health treatment. As such, researchers have explored various psychotherapeutic interventions to increase the quality of life among patients, including traditional psychotherapy, cognitive behavioral therapy, and various alternative modalities. This chapter seeks to discuss the psychological burden of psoriasis, both in relation to psychological comorbidity and overall quality of life. In addition, this chapter seeks to review evidence for psychological interventions for patients with psoriasis. A greater understanding of the mental health outcomes of psoriatic patients and psychological interventions may better equip clinicians with the necessary tools to treat psoriatic patients holistically, addressing both the physical and mental burden of the disease.

1. Introduction

Psoriasis is an immune-mediated chronic cutaneous condition characterized by pruritic, scaly plaques on the extensor surfaces of skin. Morphological forms of psoriasis include plaque, flexural, futtate, pustual,or erythrodermic psoriasis, affecting an estimated 60 million people globally [1]. In addition to cutaneous symptoms, the association between psoriasis and increased psychological burden has long been established. The early 20th century brought greater interest in investigating the relationship between psoriasis and psychological factors. In 1907, French dermatologist François detailed his observation of reduced mental health among patients with psoriasis and hypothesized psychological factors may exacerbate psoriatic severity [2]. In the early 1920s, American dermatologist William H. Goeckerman studied the efficacy of his treatment approach, the Goeckerman regimen, and noted improvements in psoriatic patients’ mental health alongside physical symptoms [3]. Similarly, John H. Ingram developed the Ingram regimen, and research detailing its associated psychological impact was published in the early 2000s [4]. Since then, various studies have explored associations between psoriasis and mental health, including psychological comorbidities, factors that increase the risk of psychological burden, the bidirectional relationship between mental health and psoriasis, and overall quality of life.

The bidirectional relationship between psoriasis and mental health describes a phenomenon in which psoriasis may increase psychological burden, while increased psychological burden may be a trigger for worsening psoriasis. Peripheral nervous system pathways, the hypothalamic-pituitary-adrenal axis, the sympathetic-adrenal-medullary system, and immune-mediated pathways collectively contribute to the relationship between psoriasis and physiological stress [5]. For example, while psoriasis may contribute to anxiety due to factors such as chronic pruritus, disfigurement, stigmatization, and reduced social support, anxiety can further contribute to psoriasis via stress disturbances in the epidermal barrier, increased stress-related neuropeptides within psoriatic plaques, dysregulation of the hypothalamus-pituitary-adrenal axes, upregulation of stress-induced mast cells, natural killer cells, and cutaneous lymphocyte-associated antigen, and increased dendritic epidermal serotonin transporter protein expression. Similarly, depression can mediate psoriatic symptoms via mechanisms such as modulating itch perception and increasing the levels of pro-inflammatory cytokines and substance P, which promotes keratinocyte proliferation, cutaneous inflammation, and lymphocyte activation [5]. Unaddressed mental health among psoriatic patients risks a vicious cycle in which disease state may worsen mental health status, which in turn can exacerbate psoriasis.

2. Psychological burden of psoriasis

2.1 Psoriasis and quality of life (QoL)

In addition to specific psychological comorbidities, studies have assessed the general association between psoriasis and quality of life. A 2004 systematic review of 17 studies found a reduced quality of life among psoriatic patients, owing to physical discomfort, impaired emotional functioning, a negative body and self-image, and limitations in daily activities [6]. Specifically, the authors found an overall mean Dermatology Life Quality Index (DLQI) of 23.4, Pain Disability Index (PDI) scores ranging from 16.5–44, Short Form-36 (SF-36) scores ranging from 41.2–55.5 (physical component) and 45.2–50.9 (mental component), and mean Sickness Impact Profile (SIP) scores ranging from 8.9 to 10.2. Table 1 details the interpretation of these scores.

QoL tool	Score interpretation
DLQI	DLQI score 0–1: no effect on QoL; DLQI score 2–5: small effect on QoL; DLQI score 6–10: moderate effect on QoL; DLQI score 11–20: very large effect on QoL; DLQI score 21–30: extremely large effect on QoL
PDI	Score range 0–45, with a higher score indicating greater QoL impairment
SF-36	Score range 0–100, with a lower score indicating greater QoL impairment
SIP	Score range 0–100, with a higher score indicating greater QoL impairment

Table 1.

Score interpretation for QoL tools.

Furthermore, authors found that higher age was associated with slightly higher levels of psychological functioning and quality of life, albeit slightly lower levels of physical functioning [6].

Given potential differences in quality of life among psoriatic patients of different ages, a 2017 systematic review and meta-analysis including 17 studies and 1185 patients evaluated health-related quality of life (HRQOL) specifically among children and adolescents with psoriasis [7]. Results revealed a weighted mean Children’s Dermatology Life Quality Index (CDLQI)/DLQI score of 7.7 (95% CI: 6.67–8.73) among studies, albeit with large study heterogeneity. Similar to the DLQI, higher CDLQI scores indicate greater negative effects on QoL. Furthermore, study samples with a higher percentage of girls were associated with greater HRQOL. In contrast, a higher mean age of onset was associated with a lower HRQOL [7].

Similarly, a 2016 study analyzing QoL among children with various dermatologic conditions found an average CDLQI score of 8.0 among patients with psoriasis (95% Confidence Interval (CI): 3.9–12.1), with a range of 0–29 [8]. Of the other analyzed dermatologic conditions, only atopic eczema (score of 8.5 (7.1–9.8)) and scabies (score of 9.2 (0–20.3)) depicted greater average CDLQI scores. Conversely, CDLQI scores for patients with psoriasis were greater than average scores for acne, alopecia, molluscum contagiosum, urticaria, vitiligo, and warts, suggesting a greater impact on quality of life [8].

2.2 Psoriasis and psychological comorbidities

In addition to quality of life, numerous studies globally have evaluated the association between psoriasis and specific psychological comorbidities. A 2023 publication detailed global epidemiology trends of mental health comorbidity in patients with psoriasis from 1986 to 2019 using five databases [9]. 56 studies were analyzed, with a cumulative prevalence of depression, anxiety, and suicide among psoriatic adults of 20%, 21%, and 0.77%, respectively. Furthermore, the respective incidence of depression, anxiety, and suicide was 42.1, 24.7, and 2.6 per 1000 person-years. Interestingly, patients in North America demonstrated a higher relative prevalence of depression and suicide, whereas patients in South America demonstrated a higher relative prevalence of anxiety [9].

Similarly, a 2017 systematic review of 34 included studies evaluated the prevalence of mental health disorders in psoriasis [10]. The prevalence of psychiatric conditions ranged from 24–90% across studies. Cumulatively, sleep disorders were the most prevalent among patients at 62.0%. Sexual dysfunction (45.6%), personality disorders (35.0%), anxiety (30.4%), adjustment disorder (29.0%), depression (27.6%), and substance-related and addictive disorders (24.8%) were also described [10].

Lastly, a 2022 analysis including 24 studies found patients with psoriasis are 1.5 times more likely to depict depressive symptoms than the general population. In addition, anxiety symptoms (20–50%), schizophrenia (2.82%), and suicidal ideation (12.7%) were more prevalent among psoriatic patients [11]. Table 2 summarizes the results of six systematic reviews that discuss psychological comorbidity and psoriasis.

Author (Year)	Studies included	Depression	Anxiety	Other
Dowlatshahi et al. [12]	98	Prevalence: 28% via questionnaires 12% via ICD codes 19% via DSM IV 9% with antidepressant use Odds: 1.57 (95% CI: 1.40–1.76)	N/A	N/A
Ferreira [10]	34	Prevalence: 27.6%	Prevalence: 30.4%	Sleep disorder: 62.0% Sexual dysfunction: 45.6% Personality disorder: 35.0% Adjustment disorder: 29.0%; Substance-related and addictive disorder: 24.8%
Lukmanji et al. [13]	17	Odds: 1.48 (95% CI: 1.16–1.89)	N/A	N/A
Jalenques et al. [14]	101	N/A	Social anxiety disorder prevalence: 15% (95% CI: 9–21%) Generalized anxiety disorder: 11% (95% CI: 9–14%) Unspecified anxiety: 9% (95% CI: 8–10%) Anxiety symptoms: 34% (95% CI: 32–37%); Odds of anxiety symptoms: 2.51 (95% CI: 2.02 to 3.12)	N/A
Hedemann et al. [11]	24	Odds: 1.5	Prevalence: 20–50%	Schizophrenia: 2.82% Suicidal ideation: 2.7%
Liu et al. [9]	56	Prevalence (adults): 20%	Prevalence (adults): 21%	Suicide (adults): 0.77%

Table 2.

Systematic reviews of psychological comorbidity and psoriasis.

Abbreviations: CI, Confidence Interval; ICD, International Classification of Diseases; DSM IV, Diagnostic and Statistical Manual of Mental Disorders IV

2.3 Factors associated with increased psychological burden

While an association exists between psoriasis and depression, anxiety, and other mental health disorders, particular disease factors may increase the risk of psychological burden. One of the most widely discussed factors associated with worse quality of life outcomes is the severity of disease. An internet-based questionnaire study conducted in China including 497 patients with psoriasis found a greater proportion of patients with severe disease to have mental stress vs. those with mild to moderate disease (99.0% vs. 73.2%, p < 0.01) [15]. Furthermore, rates of suicidal ideation were greater among those with severe disease (46.3% vs. 14.2%, p < 0.01), in addition to the proportion of patients who had suicidal behavior (6.8% vs. 1.1%, p < 0.01). Similarly, a 2020 study on the impact of psoriasis on quality of life among 51 patients found higher Psoriasis Area and Severity Index (PASI) scores had a significant impact on the psychological aspect of quality of life (r = 0.41) [16]. A higher PASI score correlated with greater anxiety, both currently and in general, and depression (r = 0.33, 4 = 0.35, r = 0.35). In addition to disease severity as measured by PASI, authors also found illness duration negatively correlated with subjective quality of life (r = −0.29) and positively correlated with anxiety and depression (r = 044, r = 0.38).

Lastly, the association between disease severity and psychological burden was illustrated in a systematic review including 13 randomized-controlled trials of biological agents for the treatment of moderate-to-severe psoriasis [17]. Authors found DLQI improvements were associated with percentage of PASI improvement from baseline; in other words, an improvement in psoriatic disease state was associated with an improvement in DLQI. Biological agents demonstrating the greatest DLQI improvement were those demonstrating >75% mean reduction in PASI. Lastly, all treatment arms that demonstrated a mean PASI reduction of at least 75% predicted a mean shift from DLQI band 3 (“very much”) to DLQI band 1 (“a little” impact on QoL) [17]. Collectively, these studies suggest increased disease severity is associated with a greater impact on QoL.

In addition to disease severity and disease duration, other factors have been described in the literature. Pruritus, one of the most reportedly distressing symptoms of psoriasis, has been associated with worse depressive symptoms [18]. Furthermore, a 2004 survey-based study including 266 patients with psoriasis in the United States found that in addition to greater body surface area affected, patient youth, and female gender were significantly associated with greater reductions in quality of life [19]. As patient youth may increase the psychological burden of disease, a 2018 interview-based study was conducted to better understand the qualitative experience of adolescents with psoriasis [7]. In total, six main themes of psoriasis-related HRQoL were described, including “physical symptoms,” “feeling different,” “psoriasis-related worry about the future,” “increased attention,” “attempts to conceal skin,” and “treatment-related frustrations and worry.” Authors described many reported challenges arising from appearance-related concerns.

Lastly, a 2021 study evaluated the association between mental health status and the level of agreement between physician and patient ratings of psoriasis severity [20]. Of the 502 patients analyzed, 43 (9%) and 49 (10%) screened positive for depression and anxiety, respectively. Overall, patients rated their psoriasis as less severe during 26% of visits and more severe during 13% of visits compared with their physician. Yet, those with positive anxiety or depression screenings were more likely to rate their psoriasis as more severe than their physician (relative risk ratio: 2.7 for depression, 95% CI: 1.6–4.5; 2.1 for anxiety; 95% CI: 1.3–3.4). Thus, the authors concluded discordance between patient and physician psoriatic severity ratings is associated with anxiety or depression [20].

2.4 Proportion of psoriatic patients seeking care for mental health

While studies suggest many psoriatic patients are not receiving optimal or timely mental health treatment, few studies exist to our knowledge delineating the proportion of patients with untreated mental health concerns. Yet, a 2023 cross-sectional study in China evaluated psychological neglect among patients with various common skin diseases, including but not limited to psoriasis [21]. Among 1010 dermatologic patients participating in the survey, 273 (27.0%) patients demonstrated a need for mental health intervention despite a lack of treatment, fulfilling the “with need” criteria. Furthermore, the authors describe contributing factors including a lack of knowledge about the availability of mental health services, a lack of knowledge regarding where to retrieve help, and concerns about treatment side effects [21]. Similarly, an internet-based questionnaire study conducted in China with 497 patients with psoriasis found up to 88.9% of patients had untreated psychological concerns [15].

While untreated mental distress appears to be prevalent among patients with psoriasis, a 96.7% weighted consensus agreement was found among 18 European experts for the following statement: “Assessing the impact on the mental health status of patients should be one of the aims of any multidisciplinary approach to elevating standards of care for patients living with psoriasis” [22]. Increased incorporation of multidisciplinary care may offset the prevalence of untreated mental health concerns. In addition, mental health discussions and resources should be provided at the time of diagnosis to ensure patients are equipped with the necessary tools to seek support, whether or not there are signs of current psychological distress.

3. Evidence-based psychological interventions for psoriasis

3.1 Current treatment recommendations

Despite the high prevalence of psychiatric disorders in psoriasis patients, there remains a notable scarcity of evidence-based clinical guidelines to help physicians effectively address these mental health concerns. As depression and anxiety are the most common psychiatric comorbidities in individuals with psoriasis, universal screening for these conditions is strongly recommended [11]. The 9-item Patient Health Questionnaire (PHQ-9) and the 7-item Generalized Anxiety Disorder Scale (GAD-7) are two common questionnaires that clinicians can incorporate into their assessments [23].

For patients exhibiting severe psychiatric symptoms or signs of suicidal ideation, a referral for psychiatric consultation is essential [11]. In such cases, involving specialized mental health professionals is crucial to ensure appropriate and timely intervention. Conversely, patients with mild or moderate psychiatric symptoms may rely on recommendations from their primary healthcare team. Interestingly, treatments aimed at managing psoriatic symptoms can also have a positive impact on depressive symptoms [24]. In addition, biologic treatments are highly recommended due to their potential to alleviate symptoms of anxiety and depression independent of skin inflammation [25]. To address the complex interplay between dermatological and psychiatric disorders, there is a growing demand for increased access to psychodermatology services. Through this multidisciplinary approach, healthcare providers can work together to improve the overall well-being and outcomes of psoriasis patients experiencing mental health challenges.

3.2 Psychotherapy and cognitive behavioral therapy

Numerous studies have demonstrated the positive effects of cognitive behavioral therapy (CBT) and other types of psychotherapy in combination with traditional dermatological treatments for improving depression and anxiety symptoms among patients with psoriasis [26]. One such study, conducted by Fortune et al. (2002), examined various psychological parameters in psoriasis patients who participated in a 6-week CBT program with weekly individual sessions in addition to their standard treatment [27]. The results revealed that integrating CBT with psoriasis treatment led to a significant reduction in the clinical severity of psoriasis (p = 0.0001), anxiety (p = 0.0001), depression (p = 0.0001), and psoriasis-related stress (p = 0.001) at both 6 weeks and 6 months post-intervention [27]. Another study, conducted by Zachariae et al., investigated the impact of 7 individual psychotherapy sessions over 12 weeks on perceived stress, as measured by the Brief Stress Questionnaire [28]. The researchers found a significant reduction in perceived stress from baseline to post-intervention in the treatment group compared to the control group (p < 0.05) [28]. Moreover, within the treatment group, there were significant improvements in psoriasis activity measures, including PASI, Total Sign Score, and Laser Doppler Skin Blood Flow [28]. These findings collectively indicate that therapy, particularly CBT and other types of psychotherapy, may play a crucial role in improving both psychological well-being and psoriasis symptoms in patients. The integration of psychological interventions alongside traditional dermatological treatments presents a promising approach to addressing the multifaceted impact of psoriasis on patients’ mental health and overall QoL. Table 3 summarizes the results of the reported two studies evaluating psychotherapy or CBT among psoriasis patients, in addition to two additional studies demonstrating significant effects.

Author (Year)	Treatment	Results
Zachariae et al. [28]	5 1.5 h individual psychotherapy sessions, in person	Significant reduction in Psoriasis Area Severity Index, Total Sign Score, and Laser Doppler Skin Blood Flow within treatment group No change within control group
Fortune et al. [27]	6 2.5 h group CBT sessions, in person	Significant reduction in the clinical severity of psoriasis (p = 0.0001), anxiety (p = 0.0001), depression (p = 0.0001), and psoriasis-related stress (p = 0.001) at both 6 weeks and 6 months post-intervention
Bundy et al. [29]	6 online self CBT modules	Anxiety scores were significantly reduced (p < 0.05) Depression scores did not change psoriasis severity scores did not change
Price et al. [30]	8 1.5 h group psychotherapy sessions, in person	Levels of anxiety were significantly reduced No significant difference in levels of depression
Singh et al. [31]	3 multidisciplinary educational sessions, every 2 weeks, 30–45 min	Significant improvements in PASI, DLQI, and WHO-5 well-being index
Larsen et al. [32]	6 motivational interviewing sessions within 3 months	Significant improvements in various measures, including Self-Administered Psoriasis Area and Severity Index scores, the three self-management domains of the Health Education Impact Questionnaire, self-efficacy scores, illness perception, and several lifestyle change parameters
Paradisi et al. [33]	3 sessions of emotional disclosure therapy (KW or PW)	PASI scores improved significantly in all three groups The PW group exhibited a significant improvement in Skindex-29 values compared to the other groups

Table 3.

Studies on various psychological interventions in psoriasis patients.

KW, King’s emotional writing intervention; PW, Pennebaker’s emotional writing intervention

3.3 Alternative psychological interventions

In addition to psychotherapy, researchers have explored the effects of various other psychological interventions on psoriasis, including group psychoeducational training, telephone-based motivational interviewing, and emotional disclosure therapy. In a 2017 study, Singh et al. assessed the impact of three psychoeducational training sessions held every 2 weeks on the severity of psoriasis and psychological outcomes [31]. The authors reported significant improvements in PASI, DLQI, and WHO-5 well-being index, indicating the effectiveness of psychoeducational training in enhancing both disease severity and emotional well-being. In addition, a 2014 study by Larsen et al. investigated the effects of a 3-month motivational interviewing intervention following climate/heliotherapy in psoriasis patients [32]. Similar to Singh et al., these researchers also observed significant improvements in various measures, including Self-Administered Psoriasis Area and Severity Index scores, the three self-management domains of the Health Education Impact Questionnaire, self-efficacy scores, illness perception, and several lifestyle change parameters. These study findings highlight the potential of using motivational interviewing to not only enhance medical management but also improve mental well-being related to the disease. Lastly, a 2010 study by Paradisi et al. explored the impact of two different emotional writing disclosure interventions on psoriasis patients undergoing ultraviolet B therapy [33]. Patients were divided into the PW group, where they were instructed to write about stressful events, the KW group, where they were instructed to write about major life goals, and the control group. Although PASI scores improved significantly in all three groups, the PW group exhibited a significant improvement in Skindex-29 values compared to the other groups [33]. This suggests that writing or talking about tense life events can be therapeutic, improve mental health and potentially improve disease status. Table 3 summarizes the results of the three studies evaluating alternative psychological interventions that have been explored and shown significant psychological effects.

3.4 Current research

As the field of psychodermatology gains momentum, there is a pressing need for more targeted research investigating these specific interventions. A comprehensive understanding of treatment options that can effectively enhance mental health outcomes for patients with psoriasis is necessary. In a 2020 analysis, researchers reviewed existing human clinical trials that assessed the effects of psychotherapy with major cognitive and behavioral components on both psoriatic and psychological symptoms. The studies encompassed diverse psychotherapy interventions, including mindfulness-based cognitive therapy and cognitive-behavioral symptom management programs [26]. Although all the studies examined psychotherapy interventions, the review highlighted the clear lack of standardization in methodology among each of the studies, leading to an inability to properly compare the studies and draw meaningful conclusions.

One notable area for improvement in future studies is the consideration of psychiatric diagnosis or symptoms during the screening process. Differing inclusion criteria across studies may influence the observed magnitude of change in psychological symptoms within each trial. Moreover, researchers should strive for greater diversity in the study population. A broader approach can lead to a better representation of the global psoriasis population and enhance the generalizability of the findings. In addition, to strengthen the reliability and validity of study outcomes, future research should incorporate more clinician-based ratings in addition to self-reported measures. Lastly, to determine the effects of psychological intervention in a controlled setting, future studies should consider requiring participants maintain a stable dermatologic regimen during their participation. A stable treatment regimen ensures that any observed changes in psychological symptoms can be more confidently attributed to psychotherapy interventions rather than fluctuations in dermatological management. By addressing these areas of improvement, future research can enhance our understanding of the interplay between psychotherapy, psoriasis, and mental health, and the findings will help guide the development of more targeted and effective interventions to improve the overall well-being of individuals living with psoriasis.

4. Conclusion

Characterized by pruritic, scaly plaques on extensor surfaces, psoriasis is an immune-mediated chronic cutaneous condition associated with a reduced quality of life and various psychological comorbidities. Research suggests the relationship between psoriasis and mental health is bidirectional; namely, psoriasis may increase psychological burden, as increased psychological burden may promote disease activity. Many psoriatic patients do not receive adequate mental health support, although researchers and clinicians alike have explored possible therapeutic strategies to foster greater quality of life among patients. Evidence exists for the efficacy of psychotherapy and cognitive behavioral therapy, both in person and online. Other assessed strategies include educational sessions, motivational interviewing sessions, and emotional disclosure therapy. Clinicians must remain aware of the potential psychological impacts of psoriatic disease in order to promptly intervene. A holistic approach is warranted for the management of psoriasis, with attention to both the physical and mental components of the disease.

Abbreviations

CDLQI	Children’s Dermatology Life Quality Index
CI	Confidence Interval
DLQI	Dermatology Life Quality Index
DSM IV	Diagnostic and Statistical Manual of Mental Disorders IV
HRQOL	Health-Related Quality of Life
ICD	International Classification of Diseases
PASI	Psoriasis Area and Severity Index
PDI	Psoriasis Disability Index
QoL	Quality of Life
SF-36	Short Form-36
SIP	Sickness Impact Profile
CBT	cognitive behavioral therapy (CBT)
PW	Pennebaker’s emotional writing intervention
KW	King’s emotional writing intervention