Should Self-help Interventions Become Routine in Psoriasis Therapy?

Liana Manolache; Andrew Y. Finlay

Disclosures

The British Journal of Dermatology. 2022;186(9):922 

Helping people with psoriasis continues to be a constant challenge for dermatologists, who may feel they carry this responsibility alone. The good news is that with the doctor–patient relationship evolving from a patient-dependency model to a shared approach in clinical decision taking, the next step is a parallel shift to shared responsibility for interventions. This change may lead to a further maturation of the doctor–patient relationship and possibly lead to even better outcomes.

Perceived stress, anxiety, depression, shame, stigmatization and reduced quality of life (QoL) are parts of the multifaceted puzzle faced by dermatologists. Despite the hugely successful search for new mechanisms and more targeted molecules to treat severe psoriasis, the patient's personality and attitudes remain poorly understood triggers and an unexplored potential therapeutic mine.

Psoriasis has not only an economic impact,[1] but also a huge influence on the patient's[2] and family members' QoL.[3] Patient QoL could be positively influenced if patients understood their disease, and if they thought their condition could be kept under control.[2]

Reinforcing these observations, Muftin et al.[4] examined the impact of online compassion-focused self-help for psoriasis, and report their findings in this issue of the BJD. In a randomized controlled trial (RCT), over 4 weeks, patients with psoriasis received either compassion-based self-help (n = 65) or mindfulness-based self-help (n = 65). The 'compassionate self-help' was designed to strengthen compassionate intention and competencies. The mindfulness self-help aimed to cultivate a soothing breathing rhythm. There were written materials and audio MP3 files with exercises: participants preferred daily audio use. Both interventions resulted in modest but significant reductions in shame, and improvements in QoL. Progress in evaluating psychological interventions in dermatology, as in other specialties, has been constrained by the lack of high quality RCTs, and Muftin et al.[4] are to be congratulated on tackling this issue with a rigorous scientific method.

Psoriasis requires a multidisciplinary approach, ideally with a psychologist being part of the team and access to psychiatry advice. An audit[5] of the provision of psoriasis therapy in hospitals in the UK and Ireland identified the persisting lack of psychological support for patients, despite longstanding recognition of this need.

Self-help intervention can be considered a first-step approach for individuals with mild levels of distress, motivating patients to seek further psychological interventions, as necessary.[4] Although their potential has not been exploited, this kind of intervention could become a first-line approach, with added cost-effectiveness benefit.[4] Beyond the statistical analysis of management approaches, the inner personality strengthening flowing from some psychological interventions is a subtle, continuous process that is hard to measure, but which sometimes has a real impact on a patient's life. Encouraging data are emerging from the 26- to 45-year old age group, especially from women,[4] who tend to be more active, more flexible in their thinking, and more open-minded to such approaches.

Psoriasis is not usually considered as an emergency, and during the pandemic many patients had no access to face-to-face consultations, causing aggravation, and there is evidence of a tendency to delay or suspend[6] therapy, in particular biologics. As online consultations became second nature for most people, audio/video interventions developed by specialists should be encouraged to support patients becoming more balanced, and to reduce their stress and increase their ability to cope.

By reducing patients' sense of helplessness and by empowering them as part of their recovery, self-help interventions could become integrated as basic therapeutic approaches in psoriasis.

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