While the need for more training and improvement in the formation of some professionals is questioned, some health professionals, usually psychiatrists, psychologists and nurses, indicate interdisciplinary referrals and treatments. In a recent guide for diagnosis and clinical management of psoriasis (Cohenm Baron & Archer, 2012), sponsored by the British Association of Dermatologists, the authors recommend a comprehensive assessment of psychosocial factors of patients accessing the impairment of QoL. For the treatment, the first step would be to educate the patient about the disease, emphasizing the management of symptoms – and not the cure – , clarifying doubts and possible myths about the disease and teaching the subjects how to apply the medication. Furthermore, it is suggested to the clinician to verify the social impact of the disease, whether the patient has social support to aid in the treatment, verifying the best treatment for each case. However, the guide recommends treatment / psychological assistance only when it is decisive to the exacerbation of psoriasis symptoms.

In addition to conventional medical therapies for symptom management, which involve pharmacological treatments (topical, systemic, biological) and phototherapy, the concern in the literature generally focuses on secondary aspects of psoriasis and its associated comorbidities. Although psoriasis is considered a psychodermatosis with relevant morbidity and their physiopathological mechanisms are increasingly involved in multi factorial processes (for example, inflammatory mechanisms and their connection to stress), one realizes that the recommendations for treatment are reduced to the forms described above. Accordingly, the aim of this work is to verify the psychological and educational interventions performed in the treatment of psoriasis, whether used as the sole treatment or as an adjunct to other therapies. As far as we are concerned, no other study attempted to systematically search this kind of intervention involving psoriatic patients.

Method

A systematic review in English and Spanish including the last 20 years (1992 through June 30, 2012) was performed in the databases of PubMed / Medline, PsycInfo (APA), and ProQuest Pepsic (Psychology Journals) including the term psoriasis combined with psychological intervention, educative intervention, psychotherapy and psychotherapy protocol. The searches were performed by a research assistant under de supervivion of a library technician from PUCRS University, who was specialized in database search. Interventions designed for psoriasis and other chronic dermatosis were included, provided that psoriasis was also included in the study. The exclusion criteria were: language other than the chosen, exclusively pharmacological interventions or phototherapy, literature review articles, case studies and cross-sectional studies evaluating psychosocial variables without psychological or educational intervention. It is considered psychological intervention treatments involving some techniques or approaches of cognitive/emotional/psychological change, such as stress management and guided imagery; the educational interventions did not involve changes on cognitive variables, only informational or behavioral variables.

Results

Initially, the computerized search indicated a total of 257 items, which were subsequently selected to have their abstracts read. Exclusion criteria at this stage involved correlational and review studies. Among these, 36 manuscripts were selected to be fully read by two assessors, all written in English language; after being completely read, 29 articles were excluded (22 were medical/physiological interventions and seven were not empirical psychological interventions) only seven studies were subsequently selected for the final analysis. Figure 1 shows the flow diagram of selected studies). The full review of potentially eligible articles were examined independently by two authors who were not blinded for the study´s criteria. Disagreements were resolved by consensus.

A brief appreciative review on the seven studies is presented as follows.

Individual cognitive-behavioral intervention – Zachariae et al, 1996

In this Danish study patients with psoriasis were randomly assigned to two groups: experimental and control. Experimental group consisted of 25 patients and underwent seven sessions of cognitive-behavioral intervention involving stress management, relaxation techniques and symptom control imagery training. The patients underwent a washout period of 14 days before the start of the study and were monitored at baseline and at the weeks four, eight and 12. The experimental group of 23 patients who completed the intervention showed a reduction of lesions compared to the control group by PASI (p = 0.06), the difference being that the percentage reduction in the PASI group was significant (p <.05). The results showed a satisfactory effect of psychological intervention, since there was no significant difference in the measurements obtained in the control group. Overall, 74% of patients in the experimental group improved symptoms, whereas the improvement was 43% for the controls.

A pilot hypnosis intervention – Tausk & Whitmore, 1999

This is a pilot study involving 11 patients with stable plaque psoriasis in the 12 months prior to the start of the study, without medication, divided into two groups. In the experimental group (n = 5) patients received suggestions for improvement of symptoms of psoriasis during hypnosis sessions. The control group (n = 6) received neutral hypnosis interventions, consisting only of suggestions aimed at relaxation. In the group that received the suggestions of symptom improvement, three subjects showed lesion improvement through PASI, decreased 81, 43 and 8%, respectively, all of which were among those who achieved the highest scores in the Stanford Scale of Hypnotizability. Of the six patients in the control group, the two persons who had the greatest reduction in lesions (31 and 18%, respectively) also had a higher score on the degree of hypnotizability, while moderately hypnotizable worsened 36 and 18%, respectively. Despite the modest sample presented, the study indicates that people with higher levels of suggestibility by hypnosis tend to get greater benefits in the clinical symptoms of psoriasis.

Study with the aid of audio tapes adjunct to phototherapy (UVB) and photochemotherapy (PUVA) – Kabat-Zinn et al., 1998

Patients with moderate and severe psoriasis (n = 37) were divided by medical indication into two groups, one receiving the phototherapy intervention only and another group with the use of psoralen added to phototherapy. The subjects were notified that the research was testing whether the experience of listening to relaxing music during the sessions of phototherapy would be nicer. The intervention for the experimental group included mindfulness meditation instruction, involving breathing, awareness of sensations, sounds, lights and air streams. At the end of the tape, they were also instructed to imagine that UV rays would be decreasing the growth and division of the skin. Four indicators for monitoring the reduction of lesions were created: first response point (first perceived change in lesions), turning point (plate begins to decrease area), halfway point (halfway through the initial injury) and clearing point (less than 5% of the initial lesions). The results point to differences between the groups with and without the use of relaxation tapes, the first 3.8 x more likely to reach the half point (p = 0.013) and point of whitening (p = 0.033). Furthermore, individuals in the tape group showed higher scores of positivity towards the sessions, a greater degree of relaxation and greater optimism towards treatment.

Symptom-management program – Fortune et al, 2002

This manuscript refers to the adaptation of the symptom management program offered by the NHS (National Health System) in the UK, previously structured for chronic pain, now adapted for psoriasis (PSMP – Psoriasis Symptom Management Programme). Amongst the psoriasis patients who were offered the program, 93 subjects were randomized into two groups by preference, one with conventional medical treatment (control) and the other with a multidisciplinary program. The intervention consisted of six cognitive-behavioral sessions, with 2.5h each, performed by doctors, nurses and psychologists. Measures taken at baseline, six weeks and six months were the following: extent of lesions (PASI), anxiety and depression (HADS – Hospital Anxiety and Depression Scale), stress (PLSI – Psoriasis Life Stress Inventory) and degree of disability (PDI – Psoriasis Disability Index). Of the 93 people who agreed to participate in the study, 40 participated in the PSMP and 53 were part of the control group. The results showed that the PASI significantly reduced at six weeks and six months (p <0.001), as well as the levels of anxiety (p <0.001) and depression (p <0.001) and disability (p = 0.04). Another finding reveals that, from the patients who participated in the program, 64% obtained clearance (> 75%), compared with only 23% of the control group.

Multidisciplinary educational program for chronic dermatosis – Lambert et al., 2011

This article was referring to a pilot study of the department of dermatology at the Hospital Ghent, Belgium, to test a multidisciplinary program aimed at improving the quality of life of patients with chronic dermatosis. The program lasted 12 weeks (2 meetings / week), and the psychological and educational activities were included in the following topics: skin care, Stress Reduction techniques, life style factors and psychodermatology information. A multidisciplinary team was composed of physical educator, dermatologist, nurse, teacher of yoga and mindfulness meditation, psychiatrist, psychologist and philosopher. Patients with psoriasis (n = 17) showed significant improvement in measures of quality of life after the intervention of the DLQI (p = 0.015), Skindex-29 (p = 0.020) and decreased their disability index with the PDI (p = 0.019).

Single Educative Intervention – Lora, Gisondi, Calza, Zanoni & Girolomoni, 2009

This manuscript portrays an educational intervention designed by a team of dermatology of Verona, Italy. Participants (n = 123) were randomized by computer to receive educational intervention of two hours by a dermatologist (educational group) or the psychoeducational group, where a psychologist accompanied the same 2h of intervention. The part that was up to the doctor was to explore the various information about psoriasis with the patient, such as the mechanisms of the disease, precipitating factors, course of disease, preventive measures and daily skin care. The group that had the presence of psychologists during the intervention received the same information, however, the end of the consultation was reserved so that they could be worked on possible negative emotions and coping strategies. Measures of quality of life (Skindex-29) and severity of pruritus were taken before and after the intervention, in addition to a six-month follow-up, where a telephone interview sought to verify that the information had been retained. The results showed an improvement in items that measured knowledge about the disease after six months (p <0.001) and a significant increase in the perception that professionals have enough to treat the disease (p <0.001). The items that measured how the person felt comfortable with psoriasis or to deal with the symptoms revealed no significant differences in both groups and in all outlets. The average PASI of the educational groups and psychoeducational groups were 9.8 and 10.8, respectively.

Randomized controlled trial using a multidisciplinary program – Bostoen, Bracke, Keuser & Lambert, 2012

The Ghent Program intervention, previously mentioned, was again applied in patients with psoriasis and atopic dermatitis. This study involved 29 patients with psoriasis, previously randomized by computer, and divided into control and experimental group. The former continued to receive conventional medical treatment alone, while the second received the multidisciplinary approach of the program. The measures of extent and severity (PASI), quality of life (Skindex-29), level of disability (PDI) and depression (BDI – Beck Depression Inventory) were assessed at baseline and three, six and nine months later. The results of PASI indicated a significant reduction of lesions in the experimental group compared to controls at three months (P = 0.036) and six months post-intervention (p = 0.017), although the reduction has not been maintained at nine months (p = 0.116). Psoriasis disability index showed a reduction at all times, three months (p = 0.015) and six months (p = 0.020) and nine months (p = 0.021), whereas the average overall rates of depression decreased significantly after nine months (p = 0.029).

Discussion

We performed a systematic review of the past 20 years about the psychological and educational interventions presented for the treatment of psoriasis. Although we have a consolidated scientific literature in the fields of psychosomatic and psychodermatology pointing to the importance of including psychological therapies and educational interventions for psoriasis, there is a noteworthy low number of articles found. Of the seven articles analyzed, five of them were created especially for the treatment of psoriasis, while two of them were aimed at the chronic dermatosis most commonly linked to psychosomatic aspects. Overall, we observed a reduced number of subjects who participated in the studies, which, on one hand, may indicate the difficulties of conducting interventional research, such as the high dropout rates. On the other hand, these data can hypothetically show poor adherence of patients for this type of intervention, since traditional treatments are offered on a larger scale and are part of the current medical standard. Only one study had a randomized clinical trial, which reflects the need to conduct further research with more rigorous methodologies. Due to the nature of the intervention, double-blind studies were not found, but only four of the seven manuscripts reported that either the professionals that performed medical tests or some of the patients' choices were blind.

In all selected studies the results were satisfactory in almost unanimity of the psychological variables. Clinical examination in one study (Zachariae et al., 1996) showed no significant improvement of the lesions in the control group, although this has shown close to significant levels. More recent studies have accessed instruments to evaluate health-related variables, such as quality of life and degree of disability of the disease, which shows a recent trend in studies with psoriasis. The variables depression and anxiety, that have long been associated with psoriasis, were measured in only two studies (Fortune et al., 2002; Bostoen et al., 2012), which may reflect a recent trend of researchers seeking broader tools that allow accessing psychosocial variables. In this sense, we can see as well the specialization of scales used in more recent studies, which showed instruments specifically designed for use in psoriatic patients, such as the DLQI, PDI and PLSI. The degree of specialization of instrumentation used and the small number of studies involving psychological and educational interventions may reflect the emphasis in studies that focus on cross-cutting research designs.