This article is Part 1 of 2 focused on complementary and alternative approaches to psoriasis. In this column we look at non-pharmacologic treatments aimed at the mind-body connection and its potential to heal. More than 7 million adults in the United States suffer from psoriasis, with 10% to 30% of these people developing psoriatic arthritis.1 Patients with psoriasis may experience significant psychological and social disabilities in addition to the physical burden of this disease. Stress is also a proposed aggravator of the disease process in psoriasis.2 Unfortunately, there is no cure for psoriasis, but there is an arsenal of heavily researched treatment options ranging from topical to systemic therapies to help manage it, relieve the discomfort it can cause, and improve the sufferer’s quality of life. Conventional Treatments Patients with mild-to-moderate psoriasis can generally be managed with topical therapies, including emollients, keratolytics, anthralin, coal tar, corticosteroids, vitamin D analogs (eg, calcipotriene), and topical retinoids (eg, tazarotene).3 For patients with moderate-to-severe psoriasis or for those with significant psoriatic arthritis, systemic therapies are increasingly used. These treatments include phototherapy, traditional systemic medications (eg, acitretin, methotrexate and cyclosporine), disease modifying anti-rheumatic drugs (DMARDs) for patients with psoriatic arthritis, and the newer immunomodulatory biologic agents: T-cell inhibitors (alefacept and efalizumab) and tumor necrosis factor (TNF) inhibitors (adalimumab, etanercept and infliximab). The Patient Perspective Although many people have found substantial relief and therapeutic success with conventional psoriasis treatments, there are patients out there who are frustrated because they have not responded to conventional treatments or they have experienced negative side effects from the treatments. Or maybe these patients just want to add something extra to their current plan. Your patients may ask you about other options, especially since some of the systemic therapies offered traditionally can have powerful side-effects and can be potentially toxic. ACUPUNCTURE: What it is Acupuncture is an old therapeutic method that includes both needle and non-needle techniques. Needle acupuncture has been used for the treatment of psoriasis for many years.4 Unfortunately, studies are lacking in terms of providing information on technique and outcomes. Studies Several uncontrolled, poorly designed studies have suggested that acupuncture is an effective treatment for psoriasis. Of these, one of the earlier studies from a Chinese group looked at acupuncture and psoriasis in 61 patients with plaque psoriasis who had not responded to conventional treatment.5 The results of this study showed 50% had complete or near-complete clearance of skin lesions after nine sessions, while about one-third had partial clearance, and 15% showed no improvement. While these results sounded promising, this study had no control group! Several years later, a more methodologically thorough study was designed by a Swedish group (Jerner et al)6 and consisted of a randomized, controlled trial involving 56 patients with plaque psoriasis who were randomized to receive either active treatment (electrostimulation by needles placed intramuscularly, plus ear-acupuncture) or placebo (sham, ‘minimal acupuncture’) twice weekly for 10 weeks. The severity of the skin lesions was scored using the Psoriasis Area and Severity Index (PASI) before, during and 3 months after therapy. After 10 weeks of treatment the PASI mean value had decreased from 9.6 to 8.3 in the ‘active’ group and from 9.2 to 6.9 in the placebo group (p < 0.05 for both groups). There was no statistically significant difference between the outcomes in the two groups during or 3 months after therapy. Thus, this study showed that acupuncture is not superior to sham (placebo) ‘minimal acupuncture’ in the treatment of psoriasis. What to tell patients Because of its popularity and efficacy in many other conditions and the increasing number of practitioners in our country who offer this service, many people may turn to acupuncture despite the lack of evidence showing that it will help for psoriasis. It may or may not be covered by a patient’s insurance and will be expensive, as several treatments will be needed. If your patients have money to spend and are looking for an alternative or adjunct to conventional therapy, there is likely no harm — but no obvious benefit — to this option. HYPNOTHERAPY: What it is Hypnosis is a therapy that has been used since ancient times to treat medical problems, including dermatologic ailments. An early definition by Marmer7 — and one that is still used today — defines hypnosis as a psychophysiologic tetrad of altered consciousness consisting of narrowed awareness, restricted and focused attentiveness, selective wakefulness, and heightened suggestibility. The mechanisms by which hypnosis produces improvement in skin disease symptoms and lesions are not fully understood but have been hypothesized to work via regulation of blood flow and other autonomic functions not usually under conscious control.8 Studies Several studies show that hypnosis has a positive effect on psoriasis.9-15 In one of the earliest hypnosis studies, a 75% clearing of psoriasis was reported in one patient using a hypnotic sensory imaging technique.12 In another case of extensive severe psoriasis of 20 years duration, marked improvement occurred using sensory imaging to replicate the feelings in the patient’s skin that he had experienced during sunbathing.13 Another case of severe psoriasis of 20 years duration resolved fully with a hypnoanalytic technique.14 After these, several case reports were published. A small (n=11), 3-month randomized, single-blind, controlled trial of the use of hypnosis in adults with stable, chronic, plaque-type psoriasis surfaced.15 Highly or moderately hypnotizable subjects were randomized to receive either hypnosis with active suggestions of improvement (five patients) or neutral hypnosis with no mention of their disease process (six patients). After this period, the study was unblinded, and all the patients were treated for an additional 3 months with hypnosis with active suggestions of improvement. Highly hypnotizable subjects showed significantly greater improvement in psoriatic lesions than did moderately hypnotizable subjects, independent of treatment group assignment (active suggestion or neutral hypnosis). Although this study included a very limited number of patients, the results suggest that hypnosis may be a useful therapeutic modality for highly hypnotizable subjects with psoriasis; further testing in a larger population would be very interesting! What to tell your patients Hypnosis has some promising evidence showing improvement in psoriasis. It may be quite useful as a complementary or alternative therapy for those patients with resistant psoriasis. It may or may not be covered by insurance, and several sessions many be needed — which can be expensive. As with acupuncture, there would be no harm in trying this modality for patients who have the desire, time and money to do so. BIOFEEDBACK: What it is This therapeutic procedure consists of making the individual aware — instant by instant — of the level of activity of one or more neurovegetative and/or somatic functions recorded by electronic devices as measurements of psychophysiological parameters (galvanic skin response, muscle tone, heart rate, body temperature, cerebral bioelectric activity, etc.) that are transformed into sensorial perceptible signals.16 The instruments used for biofeedback have buttons and knobs to command and regulate the function to be monitored and controlled by the patient. Usually there is a unit to amplify and process the signals, one to record data, and a display panel, by means of which the instrument communicates to the individual the progress of the parameter being controlled.16 Studies Although there is very little medical literature on biofeedback and psoriasis, there is a very interesting single case report of a 56-year-old Caucasian female referred for biofeedback by her dermatologist after 7 years of failed standard medical treatment for psoriasis.17 The patient underwent 13 weekly 1-hour finger/hand thermal biofeedback treatments. At the end of the treatments, all initial psoriasis lesions (a total of 11 lesions, 2- to 6-cm in size) had disappeared. Interestingly, any new psoriasis lesions that surfaced during treatment disappeared without leaving palpable or visible scarring, unlike lesions that were present prior to biofeedback treatment. During these biofeedback treatments, the patient was not doing any other therapy for her psoriasis and continued to be free of lesions at her 12-month follow-up. What to tell your patients Neither the technique nor the underlying concept has been fully developed and classified, but biofeedback is a very interesting method that may show promise as an efficacious therapeutic measure for psoriasis when correctly applied in the proper setting and in appropriate cases. For now, however, there is not enough evidence to recommend to your patients that they will see benefit, although, again, there is likely no harm in this technique. COGNITIVE-BEHAVIORAL THERAPY: What it is Cognitive-behavioral therapy (CBT) addresses dysfunctional cognitions (thought patterns) or behaviors (actions) that harm the skin or interfere with dermatologic therapy.8 CBT draws in part on identifying dysfunctional negative self-talk and substituting positive self-talk or reframing the thought picture by offering a new perspective.8 Studies There is a small amount of evidence, mostly from preliminary studies, showing that cognitive-behavioral therapy used as an adjunct to conventional therapies can result in the reduction in psychological distress18 and therefore in the clinical severity of the condition.19 In a case-control study by a British group, 93 patients with plaque psoriasis attending an out-patient psoriasis specialty clinic chose to receive standard psoriasis treatment alone (topical, systemic or combination of both; n = 53) or to enter a cognitive-behavioral therapy group (called the PSMP or Psoriasis Symptom Management Programme) as an adjunct to standard therapy (n = 40).20 They were assessed at baseline, at the end of the 6-week PSMP and after 6 months for follow-up. As compared with standard treatment alone, participation in the PSMP resulted in a greater reduction in clinical severity of psoriasis (p = 0.001), anxiety (p = 0.001), depression (p = 0.001), psoriasis-related stress (p = 0.001) and disability (p = 0.04) at 6-weeks and 6-months follow-up. This study suggests that management of the physical aspects of psoriasis and its psychological effects are significantly improved for patients involved in an integrated multidisciplinary approach. Furthermore, the techniques acquired by participation in the PSMP facilitate continued control of psoriasis for at least 6 months. What to tell your patients There is extremely limited evidence to suggest that CBT will have a positive effect on psoriasis, but as with the other modalities listed here, there is virtually no harm in trying this therapy if the patient desires. Conclusion With the available preliminary evidence, it appears that the various mind-body techniques discussed may be effective in the clinical management of psoriasis, either as an alternative to non-responsive psoriasis or perhaps more appropriately, as an adjunctive therapy. Advantages of these therapies include non-toxicity, ability to obtain a response where other treatment modalities have failed, and ability of patients to self-treat and gain a sense of control. Disadvantages include the skill of the practitioner, the lack of solid evidence of its effectiveness, and the negative social attitudes still prevalent about complementary and alternative treatments. The holistic approach recognizes that a chronic disease such as psoriasis is multifactorial, involving a confluence of genetic, environmental, social, psychological and physical events. Because of this, if your patient wants to give one of these options a try, there really is no damage done, and possibly, some benefit to be gained.
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Mind-Body Psoriasis Treatments
This article is Part 1 of 2 focused on complementary and alternative approaches to psoriasis. In this column we look at non-pharmacologic treatments aimed at the mind-body connection and its potential to heal. More than 7 million adults in the United States suffer from psoriasis, with 10% to 30% of these people developing psoriatic arthritis.1 Patients with psoriasis may experience significant psychological and social disabilities in addition to the physical burden of this disease. Stress is also a proposed aggravator of the disease process in psoriasis.2 Unfortunately, there is no cure for psoriasis, but there is an arsenal of heavily researched treatment options ranging from topical to systemic therapies to help manage it, relieve the discomfort it can cause, and improve the sufferer’s quality of life. Conventional Treatments Patients with mild-to-moderate psoriasis can generally be managed with topical therapies, including emollients, keratolytics, anthralin, coal tar, corticosteroids, vitamin D analogs (eg, calcipotriene), and topical retinoids (eg, tazarotene).3 For patients with moderate-to-severe psoriasis or for those with significant psoriatic arthritis, systemic therapies are increasingly used. These treatments include phototherapy, traditional systemic medications (eg, acitretin, methotrexate and cyclosporine), disease modifying anti-rheumatic drugs (DMARDs) for patients with psoriatic arthritis, and the newer immunomodulatory biologic agents: T-cell inhibitors (alefacept and efalizumab) and tumor necrosis factor (TNF) inhibitors (adalimumab, etanercept and infliximab). The Patient Perspective Although many people have found substantial relief and therapeutic success with conventional psoriasis treatments, there are patients out there who are frustrated because they have not responded to conventional treatments or they have experienced negative side effects from the treatments. Or maybe these patients just want to add something extra to their current plan. Your patients may ask you about other options, especially since some of the systemic therapies offered traditionally can have powerful side-effects and can be potentially toxic. ACUPUNCTURE: What it is Acupuncture is an old therapeutic method that includes both needle and non-needle techniques. Needle acupuncture has been used for the treatment of psoriasis for many years.4 Unfortunately, studies are lacking in terms of providing information on technique and outcomes. Studies Several uncontrolled, poorly designed studies have suggested that acupuncture is an effective treatment for psoriasis. Of these, one of the earlier studies from a Chinese group looked at acupuncture and psoriasis in 61 patients with plaque psoriasis who had not responded to conventional treatment.5 The results of this study showed 50% had complete or near-complete clearance of skin lesions after nine sessions, while about one-third had partial clearance, and 15% showed no improvement. While these results sounded promising, this study had no control group! Several years later, a more methodologically thorough study was designed by a Swedish group (Jerner et al)6 and consisted of a randomized, controlled trial involving 56 patients with plaque psoriasis who were randomized to receive either active treatment (electrostimulation by needles placed intramuscularly, plus ear-acupuncture) or placebo (sham, ‘minimal acupuncture’) twice weekly for 10 weeks. The severity of the skin lesions was scored using the Psoriasis Area and Severity Index (PASI) before, during and 3 months after therapy. After 10 weeks of treatment the PASI mean value had decreased from 9.6 to 8.3 in the ‘active’ group and from 9.2 to 6.9 in the placebo group (p < 0.05 for both groups). There was no statistically significant difference between the outcomes in the two groups during or 3 months after therapy. Thus, this study showed that acupuncture is not superior to sham (placebo) ‘minimal acupuncture’ in the treatment of psoriasis. What to tell patients Because of its popularity and efficacy in many other conditions and the increasing number of practitioners in our country who offer this service, many people may turn to acupuncture despite the lack of evidence showing that it will help for psoriasis. It may or may not be covered by a patient’s insurance and will be expensive, as several treatments will be needed. If your patients have money to spend and are looking for an alternative or adjunct to conventional therapy, there is likely no harm — but no obvious benefit — to this option. HYPNOTHERAPY: What it is Hypnosis is a therapy that has been used since ancient times to treat medical problems, including dermatologic ailments. An early definition by Marmer7 — and one that is still used today — defines hypnosis as a psychophysiologic tetrad of altered consciousness consisting of narrowed awareness, restricted and focused attentiveness, selective wakefulness, and heightened suggestibility. The mechanisms by which hypnosis produces improvement in skin disease symptoms and lesions are not fully understood but have been hypothesized to work via regulation of blood flow and other autonomic functions not usually under conscious control.8 Studies Several studies show that hypnosis has a positive effect on psoriasis.9-15 In one of the earliest hypnosis studies, a 75% clearing of psoriasis was reported in one patient using a hypnotic sensory imaging technique.12 In another case of extensive severe psoriasis of 20 years duration, marked improvement occurred using sensory imaging to replicate the feelings in the patient’s skin that he had experienced during sunbathing.13 Another case of severe psoriasis of 20 years duration resolved fully with a hypnoanalytic technique.14 After these, several case reports were published. A small (n=11), 3-month randomized, single-blind, controlled trial of the use of hypnosis in adults with stable, chronic, plaque-type psoriasis surfaced.15 Highly or moderately hypnotizable subjects were randomized to receive either hypnosis with active suggestions of improvement (five patients) or neutral hypnosis with no mention of their disease process (six patients). After this period, the study was unblinded, and all the patients were treated for an additional 3 months with hypnosis with active suggestions of improvement. Highly hypnotizable subjects showed significantly greater improvement in psoriatic lesions than did moderately hypnotizable subjects, independent of treatment group assignment (active suggestion or neutral hypnosis). Although this study included a very limited number of patients, the results suggest that hypnosis may be a useful therapeutic modality for highly hypnotizable subjects with psoriasis; further testing in a larger population would be very interesting! What to tell your patients Hypnosis has some promising evidence showing improvement in psoriasis. It may be quite useful as a complementary or alternative therapy for those patients with resistant psoriasis. It may or may not be covered by insurance, and several sessions many be needed — which can be expensive. As with acupuncture, there would be no harm in trying this modality for patients who have the desire, time and money to do so. BIOFEEDBACK: What it is This therapeutic procedure consists of making the individual aware — instant by instant — of the level of activity of one or more neurovegetative and/or somatic functions recorded by electronic devices as measurements of psychophysiological parameters (galvanic skin response, muscle tone, heart rate, body temperature, cerebral bioelectric activity, etc.) that are transformed into sensorial perceptible signals.16 The instruments used for biofeedback have buttons and knobs to command and regulate the function to be monitored and controlled by the patient. Usually there is a unit to amplify and process the signals, one to record data, and a display panel, by means of which the instrument communicates to the individual the progress of the parameter being controlled.16 Studies Although there is very little medical literature on biofeedback and psoriasis, there is a very interesting single case report of a 56-year-old Caucasian female referred for biofeedback by her dermatologist after 7 years of failed standard medical treatment for psoriasis.17 The patient underwent 13 weekly 1-hour finger/hand thermal biofeedback treatments. At the end of the treatments, all initial psoriasis lesions (a total of 11 lesions, 2- to 6-cm in size) had disappeared. Interestingly, any new psoriasis lesions that surfaced during treatment disappeared without leaving palpable or visible scarring, unlike lesions that were present prior to biofeedback treatment. During these biofeedback treatments, the patient was not doing any other therapy for her psoriasis and continued to be free of lesions at her 12-month follow-up. What to tell your patients Neither the technique nor the underlying concept has been fully developed and classified, but biofeedback is a very interesting method that may show promise as an efficacious therapeutic measure for psoriasis when correctly applied in the proper setting and in appropriate cases. For now, however, there is not enough evidence to recommend to your patients that they will see benefit, although, again, there is likely no harm in this technique. COGNITIVE-BEHAVIORAL THERAPY: What it is Cognitive-behavioral therapy (CBT) addresses dysfunctional cognitions (thought patterns) or behaviors (actions) that harm the skin or interfere with dermatologic therapy.8 CBT draws in part on identifying dysfunctional negative self-talk and substituting positive self-talk or reframing the thought picture by offering a new perspective.8 Studies There is a small amount of evidence, mostly from preliminary studies, showing that cognitive-behavioral therapy used as an adjunct to conventional therapies can result in the reduction in psychological distress18 and therefore in the clinical severity of the condition.19 In a case-control study by a British group, 93 patients with plaque psoriasis attending an out-patient psoriasis specialty clinic chose to receive standard psoriasis treatment alone (topical, systemic or combination of both; n = 53) or to enter a cognitive-behavioral therapy group (called the PSMP or Psoriasis Symptom Management Programme) as an adjunct to standard therapy (n = 40).20 They were assessed at baseline, at the end of the 6-week PSMP and after 6 months for follow-up. As compared with standard treatment alone, participation in the PSMP resulted in a greater reduction in clinical severity of psoriasis (p = 0.001), anxiety (p = 0.001), depression (p = 0.001), psoriasis-related stress (p = 0.001) and disability (p = 0.04) at 6-weeks and 6-months follow-up. This study suggests that management of the physical aspects of psoriasis and its psychological effects are significantly improved for patients involved in an integrated multidisciplinary approach. Furthermore, the techniques acquired by participation in the PSMP facilitate continued control of psoriasis for at least 6 months. What to tell your patients There is extremely limited evidence to suggest that CBT will have a positive effect on psoriasis, but as with the other modalities listed here, there is virtually no harm in trying this therapy if the patient desires. Conclusion With the available preliminary evidence, it appears that the various mind-body techniques discussed may be effective in the clinical management of psoriasis, either as an alternative to non-responsive psoriasis or perhaps more appropriately, as an adjunctive therapy. Advantages of these therapies include non-toxicity, ability to obtain a response where other treatment modalities have failed, and ability of patients to self-treat and gain a sense of control. Disadvantages include the skill of the practitioner, the lack of solid evidence of its effectiveness, and the negative social attitudes still prevalent about complementary and alternative treatments. The holistic approach recognizes that a chronic disease such as psoriasis is multifactorial, involving a confluence of genetic, environmental, social, psychological and physical events. Because of this, if your patient wants to give one of these options a try, there really is no damage done, and possibly, some benefit to be gained.
This article is Part 1 of 2 focused on complementary and alternative approaches to psoriasis. In this column we look at non-pharmacologic treatments aimed at the mind-body connection and its potential to heal. More than 7 million adults in the United States suffer from psoriasis, with 10% to 30% of these people developing psoriatic arthritis.1 Patients with psoriasis may experience significant psychological and social disabilities in addition to the physical burden of this disease. Stress is also a proposed aggravator of the disease process in psoriasis.2 Unfortunately, there is no cure for psoriasis, but there is an arsenal of heavily researched treatment options ranging from topical to systemic therapies to help manage it, relieve the discomfort it can cause, and improve the sufferer’s quality of life. Conventional Treatments Patients with mild-to-moderate psoriasis can generally be managed with topical therapies, including emollients, keratolytics, anthralin, coal tar, corticosteroids, vitamin D analogs (eg, calcipotriene), and topical retinoids (eg, tazarotene).3 For patients with moderate-to-severe psoriasis or for those with significant psoriatic arthritis, systemic therapies are increasingly used. These treatments include phototherapy, traditional systemic medications (eg, acitretin, methotrexate and cyclosporine), disease modifying anti-rheumatic drugs (DMARDs) for patients with psoriatic arthritis, and the newer immunomodulatory biologic agents: T-cell inhibitors (alefacept and efalizumab) and tumor necrosis factor (TNF) inhibitors (adalimumab, etanercept and infliximab). The Patient Perspective Although many people have found substantial relief and therapeutic success with conventional psoriasis treatments, there are patients out there who are frustrated because they have not responded to conventional treatments or they have experienced negative side effects from the treatments. Or maybe these patients just want to add something extra to their current plan. Your patients may ask you about other options, especially since some of the systemic therapies offered traditionally can have powerful side-effects and can be potentially toxic. ACUPUNCTURE: What it is Acupuncture is an old therapeutic method that includes both needle and non-needle techniques. Needle acupuncture has been used for the treatment of psoriasis for many years.4 Unfortunately, studies are lacking in terms of providing information on technique and outcomes. Studies Several uncontrolled, poorly designed studies have suggested that acupuncture is an effective treatment for psoriasis. Of these, one of the earlier studies from a Chinese group looked at acupuncture and psoriasis in 61 patients with plaque psoriasis who had not responded to conventional treatment.5 The results of this study showed 50% had complete or near-complete clearance of skin lesions after nine sessions, while about one-third had partial clearance, and 15% showed no improvement. While these results sounded promising, this study had no control group! Several years later, a more methodologically thorough study was designed by a Swedish group (Jerner et al)6 and consisted of a randomized, controlled trial involving 56 patients with plaque psoriasis who were randomized to receive either active treatment (electrostimulation by needles placed intramuscularly, plus ear-acupuncture) or placebo (sham, ‘minimal acupuncture’) twice weekly for 10 weeks. The severity of the skin lesions was scored using the Psoriasis Area and Severity Index (PASI) before, during and 3 months after therapy. After 10 weeks of treatment the PASI mean value had decreased from 9.6 to 8.3 in the ‘active’ group and from 9.2 to 6.9 in the placebo group (p < 0.05 for both groups). There was no statistically significant difference between the outcomes in the two groups during or 3 months after therapy. Thus, this study showed that acupuncture is not superior to sham (placebo) ‘minimal acupuncture’ in the treatment of psoriasis. What to tell patients Because of its popularity and efficacy in many other conditions and the increasing number of practitioners in our country who offer this service, many people may turn to acupuncture despite the lack of evidence showing that it will help for psoriasis. It may or may not be covered by a patient’s insurance and will be expensive, as several treatments will be needed. If your patients have money to spend and are looking for an alternative or adjunct to conventional therapy, there is likely no harm — but no obvious benefit — to this option. HYPNOTHERAPY: What it is Hypnosis is a therapy that has been used since ancient times to treat medical problems, including dermatologic ailments. An early definition by Marmer7 — and one that is still used today — defines hypnosis as a psychophysiologic tetrad of altered consciousness consisting of narrowed awareness, restricted and focused attentiveness, selective wakefulness, and heightened suggestibility. The mechanisms by which hypnosis produces improvement in skin disease symptoms and lesions are not fully understood but have been hypothesized to work via regulation of blood flow and other autonomic functions not usually under conscious control.8 Studies Several studies show that hypnosis has a positive effect on psoriasis.9-15 In one of the earliest hypnosis studies, a 75% clearing of psoriasis was reported in one patient using a hypnotic sensory imaging technique.12 In another case of extensive severe psoriasis of 20 years duration, marked improvement occurred using sensory imaging to replicate the feelings in the patient’s skin that he had experienced during sunbathing.13 Another case of severe psoriasis of 20 years duration resolved fully with a hypnoanalytic technique.14 After these, several case reports were published. A small (n=11), 3-month randomized, single-blind, controlled trial of the use of hypnosis in adults with stable, chronic, plaque-type psoriasis surfaced.15 Highly or moderately hypnotizable subjects were randomized to receive either hypnosis with active suggestions of improvement (five patients) or neutral hypnosis with no mention of their disease process (six patients). After this period, the study was unblinded, and all the patients were treated for an additional 3 months with hypnosis with active suggestions of improvement. Highly hypnotizable subjects showed significantly greater improvement in psoriatic lesions than did moderately hypnotizable subjects, independent of treatment group assignment (active suggestion or neutral hypnosis). Although this study included a very limited number of patients, the results suggest that hypnosis may be a useful therapeutic modality for highly hypnotizable subjects with psoriasis; further testing in a larger population would be very interesting! What to tell your patients Hypnosis has some promising evidence showing improvement in psoriasis. It may be quite useful as a complementary or alternative therapy for those patients with resistant psoriasis. It may or may not be covered by insurance, and several sessions many be needed — which can be expensive. As with acupuncture, there would be no harm in trying this modality for patients who have the desire, time and money to do so. BIOFEEDBACK: What it is This therapeutic procedure consists of making the individual aware — instant by instant — of the level of activity of one or more neurovegetative and/or somatic functions recorded by electronic devices as measurements of psychophysiological parameters (galvanic skin response, muscle tone, heart rate, body temperature, cerebral bioelectric activity, etc.) that are transformed into sensorial perceptible signals.16 The instruments used for biofeedback have buttons and knobs to command and regulate the function to be monitored and controlled by the patient. Usually there is a unit to amplify and process the signals, one to record data, and a display panel, by means of which the instrument communicates to the individual the progress of the parameter being controlled.16 Studies Although there is very little medical literature on biofeedback and psoriasis, there is a very interesting single case report of a 56-year-old Caucasian female referred for biofeedback by her dermatologist after 7 years of failed standard medical treatment for psoriasis.17 The patient underwent 13 weekly 1-hour finger/hand thermal biofeedback treatments. At the end of the treatments, all initial psoriasis lesions (a total of 11 lesions, 2- to 6-cm in size) had disappeared. Interestingly, any new psoriasis lesions that surfaced during treatment disappeared without leaving palpable or visible scarring, unlike lesions that were present prior to biofeedback treatment. During these biofeedback treatments, the patient was not doing any other therapy for her psoriasis and continued to be free of lesions at her 12-month follow-up. What to tell your patients Neither the technique nor the underlying concept has been fully developed and classified, but biofeedback is a very interesting method that may show promise as an efficacious therapeutic measure for psoriasis when correctly applied in the proper setting and in appropriate cases. For now, however, there is not enough evidence to recommend to your patients that they will see benefit, although, again, there is likely no harm in this technique. COGNITIVE-BEHAVIORAL THERAPY: What it is Cognitive-behavioral therapy (CBT) addresses dysfunctional cognitions (thought patterns) or behaviors (actions) that harm the skin or interfere with dermatologic therapy.8 CBT draws in part on identifying dysfunctional negative self-talk and substituting positive self-talk or reframing the thought picture by offering a new perspective.8 Studies There is a small amount of evidence, mostly from preliminary studies, showing that cognitive-behavioral therapy used as an adjunct to conventional therapies can result in the reduction in psychological distress18 and therefore in the clinical severity of the condition.19 In a case-control study by a British group, 93 patients with plaque psoriasis attending an out-patient psoriasis specialty clinic chose to receive standard psoriasis treatment alone (topical, systemic or combination of both; n = 53) or to enter a cognitive-behavioral therapy group (called the PSMP or Psoriasis Symptom Management Programme) as an adjunct to standard therapy (n = 40).20 They were assessed at baseline, at the end of the 6-week PSMP and after 6 months for follow-up. As compared with standard treatment alone, participation in the PSMP resulted in a greater reduction in clinical severity of psoriasis (p = 0.001), anxiety (p = 0.001), depression (p = 0.001), psoriasis-related stress (p = 0.001) and disability (p = 0.04) at 6-weeks and 6-months follow-up. This study suggests that management of the physical aspects of psoriasis and its psychological effects are significantly improved for patients involved in an integrated multidisciplinary approach. Furthermore, the techniques acquired by participation in the PSMP facilitate continued control of psoriasis for at least 6 months. What to tell your patients There is extremely limited evidence to suggest that CBT will have a positive effect on psoriasis, but as with the other modalities listed here, there is virtually no harm in trying this therapy if the patient desires. Conclusion With the available preliminary evidence, it appears that the various mind-body techniques discussed may be effective in the clinical management of psoriasis, either as an alternative to non-responsive psoriasis or perhaps more appropriately, as an adjunctive therapy. Advantages of these therapies include non-toxicity, ability to obtain a response where other treatment modalities have failed, and ability of patients to self-treat and gain a sense of control. Disadvantages include the skill of the practitioner, the lack of solid evidence of its effectiveness, and the negative social attitudes still prevalent about complementary and alternative treatments. The holistic approach recognizes that a chronic disease such as psoriasis is multifactorial, involving a confluence of genetic, environmental, social, psychological and physical events. Because of this, if your patient wants to give one of these options a try, there really is no damage done, and possibly, some benefit to be gained.
