Psoriasis Is More Than Skin Deep

Psoriasis vulgaris is a chronic, inflammatory disease that affects over 7.5 million people in the United States alone.^[1] People with psoriasis can experience a range of signs and symptoms from lesions on the skin to severe arthritis.^[2] Typically psoriasis appears as red inflamed skin lesions that are covered in a dry, silvery scale.^[3] However, mental health issues may extend beyond the embarrassment and anxiety caused by what is visible. One study reported that up to 84% of people with psoriasis experience psychological distress.^[4] (See Table below) 

The Psychological Burden of Psoriasis

Psoriasis is associated with psychiatric conditions more often than other skin conditions.^[5] The complex association between psoriasis and psychiatric/mental disorders has been studied by researchers.^[6] Is the burden of having psoriasis causing depression and anxiety, or is an underlying psychiatric disturbance worsening the physical manifestations of psoriasis? There may be underlying mechanisms that create a two-way street leading to a vicious cycle between declining mental health and worsening psoriasis symptoms. In a systematic review looking at a large portion of the medical literature at once, the most prevalent psychiatric disturbances associated with psoriasis were sleep disorders and sexual dysfunction.^[6]

Over 50% of all people with psoriasis may suffer from sleep problems, and the prevalence of sexual dysfunction in psoriasis patients may be over 70%.^[5] Substance abuse or dependence is commonly reported in patients with psoriasis, including using alcohol and cigarettes as a way of coping.^[7] “Difficulties with alcohol” have been reported by up to 30% of people with psoriasis.^[8] Over 80% of people with psoriasis may suffer from anxiety,^[9] and over 60% may suffer from depression.^[10,11] One study even suggested an increased risk for schizophrenia in people who have psoriasis, although the reason for this possible link is not clear.^[12]

Stress Worsens Psoriasis in a Vicious Cycle

One explanation for why psychological and psychiatric conditions are associated with psoriasis may be that special hormone systems involving “fight or flight” hormones (norepinephrine and epinephrine) and stress hormones (cortisol) may be abnormal in psoriasis sufferers.^[6] Anxiety and stress might make psoriasis worse. People with chronic anxiety have elevated cortisol levels that may disrupt the normal skin barrier, leading to worsening psoriasis.^[5]

Stress may also cause dysregulation of the immune system, promoting inflammation in psoriasis.^[13] Psoriasis might lead to mood disorders. Several factors may understandably contribute to the development of mood disorders in psoriasis sufferers, including physical disfigurement,^[14] chronic itch,^[15] poor treatment results,^[5] or a history of depression.^[16]  

The etiopathogenesis of the connection between psoriasis and mood disorders is broad. Stress, inflammation, mood disorder, and psoriasis may all exist within one vicious cycle.^[3] It is important for people with psoriasis, their family members, friends, and healthcare team to be aware of the high prevalence of mood disorders associated with psoriasis to ensure proper treatment.

Treatment Options for the Stress of Psoriasis 

SSRIs

Depending on the person, different methods of treatment are available for people with psychiatric disturbances. While a class of medications called SSRIs is commonly prescribed for mood disorders, a few studies have reported a triggering or worsening in psoriasis after starting an SSRI called fluoxetine.^[17,18]

Cognitive Behavioral Therapy

Another study demonstrated that cognitive behavioral therapy (CBT) led to a significant reduction in depression and anxiety scores. In addition to feeling better mentally, 64% of these patients also had a 75% psoriasis clearance after 6 months of CBT, compared to 23% in the control group.^[19] This demonstrates the intertwined relationship between mental health and psoriasis severity and the importance of recognizing a psychiatric disturbance so that treatment is thought of more holistically beyond the skin disease.