Stress as an Influencing Factor in Psoriasis

Misha M. Heller, BA; Eric S. Lee, BS; John Y.M. Koo, MD

Disclosures

Skin Therapy Letter. 2011;16(5) 

In This Article

Therapeutic Overview

Psychotherapy and Stress Reduction

Psychotherapy may be beneficial for psoriasis patients. Seng et al.[21] found group therapy to be a useful and supportive treatment. Group therapy provided patients with knowledge about psoriasis and helped them better cope with their skin disease. Talking to other psoriasis patients enabled participants to learn how to manage disease-related stress and gain self-confidence.[21]

Case reports have described improvements in psoriasis severity with relaxation and stress reduction techniques, such as hypnosis and thermal biofeedback.[22,23] Likewise, Price et al.[24] showed the potential efficacy of psychotherapy in a study of 11 patients, who completed an eight-session intervention consisting of relaxation and cognitive techniques. Patients reported a significant reduction in levels of anxiety and showed improvements in psoriasis severity based on a visual-analogue scale examining area of involvement, erythema, induration, and scaling.[24]

Additionally, in a study of 37 patients treated with ultraviolet B (UVB) or PUVA therapy, Kabat-Zinn et al.[25] found that stress reduction may help accelerate the rate of clearance. Patients were randomly assigned to either an audiotape-guided, meditative stress reduction exercise during the light treatment, or a control group consisting of the light treatment alone. Study findings revealed that patients in the stress reduction group reached the clearing point (or the point at which less than 5% of the baseline level of psoriasis remained) more rapidly than controls in both UVB and PUVA therapies.[25]

Pharmacotherapy and Stress Reduction

Pharmacotherapy may also be a helpful adjunct to psoriasis treatment. Studies have demonstrated improvements in psoriasis with oral administration of antidepressants, such as the tricyclic antidepressant (TCA) imipramine (Tofranil®), the monoamine-oxidase inhibitor (MAOI) moclobemide (Manerix®), and buproprion-SR (Wellbutrin®).[26–29]

Modell et al.[29] found that the norepinephrine-dopamine uptake inhibitor buproprion-SR may be effective in treating non-depressed individuals with psoriasis. Ten patients were given buproprion-SR monotherapy at 150 mg/day for 3 weeks, and then increased to 300 mg/day for 3 more weeks. Only one patient remained on 150 mg/day dosing for all 6 weeks. Eight out of the 10 patients showed improvement from baseline after 6 weeks of therapy, with an average body surface area reduction of about 50%. Of these eight responders, disease severity worsened (towards pre-study baseline psoriasis coverage) within 3 weeks of discontinuing buproprion-SR.[29]

In contrast, there are also a total of six cases reporting that the selective-serotonin reuptake inhibitors (SSRIs) fluoxetine (Prozac®) and paroxetine (Paxil®) may induce or exacerbate psoriasis.[30–32]

Pharmacologic Treatment Recommendations

When pharmacologic treatment is deemed appropriate for stress reduction, SSRIs should be considered for first-line therapy. Despite the six reported cases of SSRI-associated flares of psoriasis,[30–32] SSRIs have certain merits in the treatment of psoriasis patients experiencing depression. As well, these agents may possibly confer adjuvant benefits for non-depressed psoriatics who are stress responders. SSRIs, such as fluoxetine, paroxetine, sertraline (Zoloft®), and escitalopram (Lexapro®), are generally safe and better tolerated than other classes of antidepressants.[33]

In stress responders, paroxetine may be preferential because of its anti-anxiety effects. It also offers the advantage of having minimal anticholinergic activity and no associated weight gain. Common side-effects include headache, gastrointestinal upset, and sexual dysfunction.[33]

TCAs, though effective antidepressants, can be lethal in overdose. Side-effects are common and include sedation, weight gain, orthostatic hypotension, and anticholinergic effects. MAOIs may be used to treat patients whose symptoms do not respond to first-line antidepressants (also known as, refractory depression). MAOIs should be prescribed with caution because of their potentially dangerous side-effects (i.e., serotonin syndrome and hypertensive crisis). Common side-effects include orthostatic hypotension, drowsiness, weight gain, sexual dysfunction, dry mouth, and sleep dysfunction.[33]

In addition, anti-anxiety medications may be helpful for short-term use in specific stressful situations for stress responders. For instance, alprazolam (Xanax®) is a rapid-acting medication, with both anti-depressant and anti-anxiety effects, that may be beneficial in these situations. Because it has a shorter and more predictable half-life, as compared with other benzodiazepines, there is less risk of accumulation in the body when used over long periods of time. However, alprazolam can be highly sedating and potentially addictive,[34] and therefore, treatment should be limited to short-term use on the order of a few weeks to a maximum of a few months.

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