August marks Psoriasis Awareness month, a time to spread information about the condition and treatment options, as well as to support those who experience it. This post is dedicated to understanding psoriasis, the link with stress and mental health and education on treatment options.
- What is psoriasis?
- Inflammatory skin condition affecting 1-3% general population.
- Multifaceted condition consisting of autoimmune, genetic, and environmental components.
- Over-proliferation of skin leads to the characteristic thick scaly plaques associated with psoriasis.
- Can affect any skin surface and the nails.
- Manifests as pink plaques on the skin covered with a silvery scales, has a preference for elbows, knees and the scalp, can affect the nails (causing thickening, easy breakage, ‘pitting’ – little dents in the nail, ‘oil spots’ – discolouration), can also present as lots of little plaques all over (‘guttate’ psoriasis), widespread large plaques, or even isolated areas (e.g. genital, scalp).
- Picking off scales can lead to bleeding.
- ITCHY! This is not a common symptom that people with psoriasis are asked about, but it can be very debilitating and affects sleep.
- Usually presents later in life (late teens to adults, but there are cases in childhood).
- Can be associated with other medical problems like obesity, high blood pressure, diabetes, high alcohol intake, throat infections.
- Risk of joint involvement, this can manifest as pain, swelling or difficulty in movement.
- Can be caused by drugs! Including medications for blood pressure (bisoprolol) and mental health issues (lithium).
Can sometimes be confused with eczema, and there are some cases where both conditions overlap. Eczema however usually presents in childhood, likes the creases of the skin (behind the knees, in the elbow creases) and is not usually very scaly.
- Tell me about stress and psoriasis
- Stress causes the release of certain hormones that activate inflammatory pathways in the brain that can in turn affect the skin to cause and aggravate skin conditions. Psoriasis is an example of this.
- The link between stress and psoriasis has been well researched, stress can worsen psoriasis and vice versa. The link between stress and skin is skin can be explained by the Hypothalamic-Pituitary-Adrenal axis (HPA-axis or ‘stress’ axis). This is a stress-activated pathway that starts in the brain and causes release of various chemicals and hormones that drive inflammation both in the body and the skin.
- It can be like a vicious circle as stress can precipitate and aggravate psoriasis, this is exactly why it is so important to recognise stress and deal with it. The more people with psoriasis understand their condition and the relationship to stress or mood, the better we can control their symptoms. Of course, this may not work for all people with psoriasis, but having a holistic approach to skin conditions can make patients realise that there are a number of ways to manage their condition.
- There are several ways to manage stress, and this will vary from person to person. It is imperative to first treat the condition adequately. Having better control of symptoms and signs of skin disease generally has a positive impact on mood and stress levels. Countless times I have heard from my psoriasis patients that as their skin got better so did everything else!
- Addressing itch – people with psoriasis can be very itchy, and this can be overlooked. Itch can be tackled with better treatment of their skin and adjunctive treatments like antihistamines or habit-reversal therapy (to break the itch-scratch cycle).
- Addressing sleep – I recommend at least 8 hours of sleep a night and will discuss sleep hygiene techniques with patients (e.g. no social media for 1-hour before bed, limit caffeine intake, having a sleep routine).
- Diet and exercise – the positive effects of a healthy diet and exercise are well known and can enhance mood or act as stress-busters!
- Identifying triggers – in order to manage stress, it is important to work out what the potential triggers are. I suggest keeping a diary or using an App to monitor feelings of stress/anxiety, patients can then work back to identify triggers.
- Managing stress – this largely depends on what the trigger is but I do suggest some general approaches:
- Mindfulness – this is a widely accessible psychological intervention that encourages people to acknowledge feelings of stress/anxiety and then move on from those feelings to be able to function optimally. The Headspace App is a good starting point.
- Relaxation therapies – people are less able to relax due to everyday pressures and often this can build up to cause feelings of being overwhelmed. Taking 10mins at the beginning and end of the day to practise relaxation through breathing exercises or muscle stretching (which can be done in bed!) can have a positive impact.
- Positive affirmations – people with psoriasis report high levels of psychological distress. Having some positive thoughts can help to overcome or at least lessen negative feelings. Having five positive statements about yourself and repeating this daily at intervals (or at stressful times) can elevate mood and improve coping strategies.
- Other psychological therapies – if people are unable to manage stress themselves using the self-help techniques described above I do suggest they talk to their healthcare provider about being referred to ‘Talking Therapies’ (psychology services accessible via GP’s) so they can have a more in-depth discussion about how they are feeling and work out strategies to improve coping with a professional.
- Medical management – overwhelming stress can lead to clinical levels of anxiety and depression. For some patients this means oral medication, this is not unusual and can be extremely helpful for those people who are unable to overcome negative feelings.
- Stress can be unavoidable, or unmanageable. In situations where a patient with psoriasis is having a flare of their physical symptoms as well, I suggest
- Appropriate medical management of the flare – for example, stepping up current treatment, or if flares are occurring very often, considering a different treatment approach. Your dermatologist is best at advising on how to move things forward.
- Take appropriate time out – people with psoriasis may not feel that their skin can be a reason to ask for time off work or take sick leave, if the symptoms are unmanageable then it definitely is! If you are comfortable with sharing information about your skin condition with those close to you or your employer then do, it may help them to support you.
- If a flare is not settling please do contact your dermatologist of other healthcare provider for help/advice.
- What is the link between psoriasis and mental health?
- Well documented links with adverse mental health outcomes like depression, anxiety and suicidal behaviour.
- Associated with poor quality of life, low mood, emotional upset, relationship issues, problems with intimacy, poor body image, financial burden (e.g. leaving work because of poorly controlled disease). In addition, people with psoriasis are socially isolated, have feelings of defectiveness and failure, are vulnerable to harm, and can feel dominated.
- People with psoriasis also find it difficult to express their emotions, so they are more likely to miss opportunities to disclose how they are feeling. Ultimately, this leads to poor coping and may aggravate psychological distress.
- Up to 84% of patients with psoriasis have a co-existing psychiatric diagnosis. Psoriasis is specifically linked with an increased risk of depression. More severe disease may result in a higher risk of developing depression, especially in young male patients.
- At the time of diagnosis, people with psoriasis have shown to have higher prevalence of alcohol misuse, bipolar disorder, depression (62%), anxiety disorders (25-30%) and self-harm, and are more likely to be taking medication to manage their mental state. Psychiatric conditions can be attributed to progression of psoriasis as well as causing it.
- New research shows that the inflammation seen in the skin may extend into the brain and cause symptoms of low mood.
- All doctors working with patients with chronic skin conditions like psoriasis should be making an assessment on the psychological impact of the disease.
- Patient support groups have also been instrumental in increasing awareness of the psychological impact of psoriasis.
- How can I take care of my mental health if I have psoriasis?
- I encourage people with psoriasis to first discuss their skin with appropriate healthcare professionals to ensure they are receiving adequate treatment. It is also important to disclose the effect skin is having on key quality of life aspects like sleep, exercise, relationships, clothing choices, and work/study. By understanding the impact of psoriasis on the life of the patient is the best way to ensure optimal treatment. This is the first step to taking control of the associated mental health aspects.
- If despite good medical management, mental health issues still exist, then this may be an indicator for other therapies. This includes psychological interventions and, in some cases, oral medications to deal with symptoms of psychological distress. Lifestyle factors also play an important role, for example, reducing alcohol intake, stopping smoking, considering healthier food choices and increasing exercise. All of these can also positively impact mental health. People with psoriasis are at higher risk of other medical conditions (e.g. heart disease, high blood pressure, stroke, high cholesterol, diabetes), it is important to discuss these with a healthcare professional to manage patients more holistically.
- Keeping in touch with approved websites and patient support groups is another way to increase knowledge about psoriasis and to gain some social support. By staying informed patients are empowered to make better decisions about their skin and mental health.
- How do you treat psoriasis?
- Management of psoriasis depends on how much of the skin is affected, associated conditions and effect on quality of life. The psychodermatological approach considers the patient as a whole, so all factors are appropriately addressed.
- Topical treatments include:
- Tar/salicylic acid combinations
- Calcipotriol (a form of vitamin D)
- Moderate potency steroids OR
- Combinations of moderate potency steroid/calcipotriol/salicylic acid
- Calcineurin inhibitors (suppresses the immune reaction in the skin, do NOT contain steroids)
- Phototherapy is another option and includes narrowband UVB or PUVA.
- Oral options for systemic treatments include Retinoids (e.g. acitretin), Immunosuppression (e.g. methotrexate, ciclosporin and mycophenolate mofetil) or Other options such as fumaric acid esters, apremilast.
- Injectable treatment, otherwise known as biologics, include TNF inhibitors, IL-12/23 antagonists, IL-17A inhibitors, or other targeted biologics. To qualify for injectable treatment in the U.K. an individual needs to have a certain level of severity of psoriasis, along with a recognised impact on quality of life.
- Non-pharmacological options include diet and lifestyle modification, counselling, cognitive behavioural therapy, acceptance and commitment therapy and mindfulness (amongst the most common).
- I have psoriasis, what should I do?
- Learn about your condition, understand what psoriasis is and how it affects your body (not just the skin).
- Talk to people you trust about how your skin affects your life.
- Discuss with your doctor about what treatments are available and if you are not satisfied do not be afraid to ask for a second opinion via a consultant dermatologist or psychodermatologist.
- Psoriasis is associated with high blood pressure, obesity and diabetes, keep a check on these with your GP.
- If you feel low about your skin or life please let your doctor know, there are lots of things we may be able to do to help.
- Keep up to date with research in psoriasis and if you can take part in registered clinical trials, this is a great way to contribute to research.
- If you are trying to support a family member/friend/colleague with psoriasis, encourage them to seek appropriate treatment, maybe offer to go to an appointment with them for support, ask them how their skin makes them feel, and ask how you can help them in their journey with their skin.
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