One of the earliest investigations into the effects of meditation and guided imagery on psoriasis was conducted by Gaston et al in 1988.¹⁶ This 18-person study spanned 12 weeks and employed a three-arm design, comprising a meditation group, a meditation with imagery group, and a waitlist control group. Participants in the meditation groups were instructed in an “opening-up” meditation technique, which involved broadening attentional focus towards bodily sensations. Participants assigned to the meditation with imagery condition were additionally guided to visualize an image representing their psoriatic lesions and then generate a transformative image to heal the lesions. The results indicated a significant improvement in psoriasis severity in both meditation groups compared to the control group (p<0.01). No significant additive benefit was observed in the guided imagery group compared to the meditation-alone group. Despite the study’s limited sample size, these findings provided initial evidence for the therapeutic potential of meditation in alleviating psoriasis severity.

Kabat-Zinn et al conducted a randomized, controlled trial to investigate the impact of mindfulness meditation-based stress reduction on skin clearance rates in 37 patients with moderate to severe psoriasis undergoing phototherapy and photochemotherapy treatments.¹⁷ The patients were randomly assigned to either an experimental group, which received mindfulness meditation instruction via audiotape during light treatment sessions, or a control group which only received light treatments. The mindfulness meditation recordings focused on cultivating present moment awareness and a non-judgmental attentional stance, guiding participants through mindful awareness of bodily sensations, emotions, thoughts, and ambient sounds. As the meditation time was increased during the study, participants were asked to visualize ultraviolet light decelerating the growth and division of their skin cells. The results demonstrated that patients in the meditation group achieved statistically significant faster rates of skin clearing compared to those in the control group (p=0.01).

To explore the efficacy of mindfulness-based cognitive therapy (MBCT) as an adjunctive treatment for psoriasis, Maddock et al conducted a randomized controlled trial of its effectiveness on the psychological well-being, including anxiety and depression, of 101 patients with psoriasis.²² The study also explored the influence of MBCT on several psychological domains suggested by a Buddhist-influenced model, such as acceptance, mindfulness, and self-compassion. Results indicated that MBCT significantly improved self-reported symptoms of psoriasis (p=0.01) as well as psychological well-being, reducing anxiety (p=0.02) and depression (p=0.02) compared to the control group. These improvements were present immediately after the course of treatment and for some measures (depression, rumination, worry, mindfulness, non-attachment, and self-compassion) at the three-month follow up.

The effectiveness of an internet facilitated, electronic cognitive-behavioral (eCBT) program for psoriasis has also been evaluated by Bundy et al and Van Beugen et al.^19,25 The two studies, when combined, randomized 268 participants to receive either an eCBT treatment or treatment as usual. Those in the eCBT group benefited from statistically significant reduced anxiety levels (p=0.03) and improved quality of life (p=0.03),¹⁹ and improved physical functioning (p=0.03) and impact on daily activities (p=0.04).²⁵ There were no statistically significant differences in psoriasis severity in either group. Of note, Bundy’s study had a 43% drop out rate.

Motivational interviewing (MI) is a patient-centered counseling method that aims to enhance intrinsic motivation and commitment to behavior change. Larsen et al explored the impact of a telephone-based MI on 169 patients with psoriasis following climate therapy.²¹ Psoriasis patients who received MI showed significant improvements across multiple outcomes, including a significant reduction in disease severity, with significant improvements persisting at both three and six months post-intervention compared to the control group. Additionally, the intervention positively influenced various self-management capacities, with enhancements noted in several domains in the Health Education Impact Questionnaire (heiQ), particularly in self-efficacy scores at similar intervals (p<0.05). The study also found that psoriasis knowledge was significantly better in the intervention group at 6 months (p=0.01), suggesting that MI can effectively augment patient education.

Not all mindfulness-based therapies have shown a beneficial effect in patients with psoriasis. D’Alton compared three different mindfulness interventions—MBCT, mindfulness-based self-compassion therapy, and a self-help version of mindfulness-based self-compassion therapy—against treatment as usual for psoriasis (n=94).²⁰ The intervention group showed no statistically significant improvement in psychological well-being, symptom burden, or quality of life compared to the control group, although some participants reported personal benefits. Nguyen et al explored the efficacy of Mindfulness-Based Stress Reduction (MBSR) in patients with either psoriasis (n=20) or rheumatoid arthritis (n=15).²³ The results showed no statistically significant improvement in wellness or quality of life.

Psychotherapy focused on stress management has been studied in AD. Habib et al evaluated the effectiveness of a psychoeducational stress management program as an adjunct treatment for AD (n=17).²⁹ The intervention group experienced significant reductions in itchiness and overall severity of dermatitis (p=0.03), with improvements sustained at the 8-week follow-up. Participants also reported decreased levels of social anxiety and self-consciousness about their appearance (p<0.01). Similarly, Schut et al conducted a randomized controlled trial to investigate the effects of cognitive behavioral stress management (CBS) on patients with AD (n=28).³⁵ The results showed reduced morning cortisol levels and a reduced cortisol response to acute stress in the intervention group (p=0.04). No significant difference in skin status was noted on the Scoring Atopic Dermatitis scale (SCORAD).

The efficacy of eCBT has also been explored for AD. Hedman-Lagerlöf et al used eCBT-based exposure therapy to reduce the effect of triggers on AD exacerbation (n=102).³⁰ The intervention group showed statistically significant improvements eczema severity (p<0.01), itch intensity (p<0.01), perceived stress (p<0.01), sleep problems (p<0.01), and depression (p<0.01). These improvements were maintained at 12 month follow-up. Kishimoto et al used eCBT to increase mindfulness and self-compassion (n=107), resulting in significant improvement in DLQI scores (p<0.01), indicating enhanced quality of life and better management of their condition. Secondary outcomes also improved, such as itch and scratching measured by visual analog scales, and psychological symptoms.³¹

Ehlers et al investigated the effectiveness of relaxation training combined with psychotherapy in AD.²⁸ The subjects (n=113) were divided into four group groups: dermatological education (DE), autogenic relaxation training (AT), cognitive-behavioral treatment (BT), and a combined DE and BT approach (DEBT). The psychological treatments (AT, BT, DEBT) led to significantly greater improvements in skin condition compared to DE or only standard medical care (p<0.05). Notably, these improvements were sustained at a 1-year follow-up. Significant reduction in the use of topical steroids was also observed among patients who underwent psychological treatments (AT, BT, DEBT), with the DEBT group reporting the largest decrease.

Bae et al studied the efficacy of Progressive Muscle Relaxation (PMR) in reducing symptoms of AD (n=25). Serological parameters associated with anxiety were also examined. The findings revealed statistically significant improvements in the PMR group compared to the control group, with reduction of pruritus (p<0.05) and improved sleep (p<0.05). Anxiety levels, measured by State Anxiety scores, also improved in the PMR group. No significant changes were observed in serological parameters such as nerve growth factor, neuropeptide Y, or Th2 cytokines (IL-4, IL-5, and IL-13) in either group.³⁷

Chatzikonstantinou et al explored the effectiveness of the Pythagorean Self-Awareness Intervention (PSAI) for managing acne vulgaris.³⁸ The PSAI involved a daily practice of self-reflection, asking participants to consider three questions: What have I done wrong? What have I done right? What have I omitted that I ought to have done? The study included 30 female participants, randomly assigned to either the control group or the PSAI group. Over an 8-week period, 93.3% of participants in the intervention group experienced improvement in acne stages compared to 26.7% in the control group (p<0.01). The study also reported large to moderate statistically significant effects on reducing perceived stress and negative affect among participants in the intervention group, with no reported dropout or side effects, and a 100% compliance rate.

Kelly et al evaluated two self-help interventions designed to reduce depression in self-critical individuals with acne vulgaris by improving their ability to soothe themselves and resist self-attacks.³⁹ The study (n=75) recruited participants who reported psychological distress related to their acne vulgaris. The participants were randomly assigned to receive self-soothing training, attack-resisting training, or to the control group. Both interventions involved daily imagery-based self-talk exercises over a two-week period. The attack-resisting training significantly reduced symptoms of depression, shame, and skin complaints, particularly in individuals who initially scored high in self-criticism. The self-soothing training significantly reduced feelings of shame and skin complaints but did not significantly impact depression levels. Both of the interventions significantly lowered the frequency with which participants were bothered emotionally, functionally, and physically by their acne as assessed with SKINDEX-16. The intervention group reported that their acne had improved, but these results were based on self-report only. The study found that the interventions were particularly beneficial for those with high levels of self-criticism, suggesting that individualized approaches may be beneficial in treating patients with acne vulgaris and psychological distress.

In a randomized controlled trial, Mashayekhi et al examined the efficacy of CBT as an adjuvant treatment for acne excoriée, a condition characterized by the compulsive picking or scratching of acne lesions, leading to the formation of crusts and scars.⁴⁰ The participants (n=32) were divided into a control group or an intervention group. Both groups received standard treatment. The CBT group also participated in eight CBT sessions over two months. The CBT group showed significantly greater improvements in clinical severity (p=0.01) and self-reported Skin Picking Scale scores (p=0.02) compared to the control group, along with notable reductions in both depression and anxiety.

Overall, these studies provide evidence that incorporating psychological interventions into the management of acne vulgaris can lead to significant improvements in both physical symptoms and associated psychological distress. The effectiveness of these interventions may vary depending on the specific type of acne, the individual's psychological characteristics (eg, tendency to self-criticism), and their adherence to the treatment plan. Further research is needed to establish the long-term effectiveness of these interventions and to determine the optimal combination of psychological and medical treatments for each patient.

Piascero et al examined the benefits of combining biofeedback and CBT compared to standard ultraviolet B (UVB) therapy in treating psoriasis.⁴³ Forty participants were randomized to receive UVB light either alone or in combination with CBT and biofeedback. The biofeedback targeted muscle tension, skin conductance level (SCL), skin temperature, respiratory patterns, and heart rate. Participants who received UVB therapy in combination with biofeedback and CBT showed a greater reduction in both the area and severity index of their psoriasis compared to those who only received only UVB therapy. In the combined treatment group 65% of participants achieved 75% or greater reduction in PASI scores from baseline (PASI75) after eight weeks, compared to only 15% of participants of the control group (p<0.01). Additionally, the group who received CBT and biofeedback showed significant improvements in the emotional domain of the Skindex-29, a measure of skin disease-related quality of life (p=0.04).

Of note, Piascero’s results differ from an earlier study by Keinan et al who compared 1) phototherapy alone to 2) phototherapy plus relaxation therapy, to 3) phototherapy plus relaxation therapy and electromyography biofeedback (EMG), which is designed to reduce muscle tension.⁴² The study enrolled 32 psoriasis patients. The relaxation group was taught an abbreviated version of progressive muscle relaxation in which they were trained to gently flex then relax muscle groups. The study showed no significant differences between any of the groups in psoriasis symptom improvement; however, the biofeedback and relaxation groups reported statistically significant improvement of their psoriasis symptoms relative to the previous year during the same season, while improvement in the phototherapy group relative to the previous year did not reach statistical significance.

To assess the efficacy of biofeedback-assisted relaxation and cognitive imagery in treating acne vulgaris, Hughes et al conducted a study (n=30) of patients who were receiving dermatological treatment.⁴⁴ Participants were matched by age, sex, and pre-treatment acne severity and then randomly assigned to one of three groups. All participants continued medical treatment. The treatment group received instructions on the use of imagery to control acne, and was trained in EMG biofeedback, using patterned breathing and thoughts of relaxation to reduce muscle tension. The second group received group therapy and education for the same amount of time as the biofeedback group and were assigned the same daily home practice assignments. The third group received no treatment beyond their usual medical care. The treatment consisted of 12 sessions over six weeks. The biofeedback group showed significant improvements, with a notable reduction in acne severity, compared to the other two groups (p<0.01). However, this improvement was maintained at follow-up only by those who continued home practice; the improvement diminished for those who discontinued home practice.

Body relaxation training in addition to other psychotherapeutic interventions may benefit psoriasis patients. Fortune et al added a body relaxation component to a cognitive-behavioral psoriasis symptom management program.⁴⁶ The study included progressive muscle relaxation training with didactic education about psoriasis and its treatments, stress reduction techniques including autogenic training, and cognitive techniques to help participants (n=93) manage maladaptive thought processes. Participants who participated in the intervention program demonstrated significantly better outcomes compared to those who received standard treatment alone, including reductions in the clinical severity of psoriasis (p=0.04), as well as reductions in anxiety (p=0.04), depression (p<0.01), psoriasis-related stress (p<0.01), and disability (p<0.01). These improvements were maintained at both the six-week and six-month follow-up assessments.

Treatments focusing on body relaxation without a psychological component were studied by Price et al and Neerackal et al. In the study performed by Price et al (n=31) the intervention group learned relaxation techniques and participated in group discussions for eight weekly sessions.⁴⁸ The results showed a statistically significant (p<0.05) reduction in anxiety scores from the initial assessment to the 6-month endpoint in the treatment group compared to the control group. There was a trend towards clinical improvement in psoriasis scores, but it did not reach statistical significance. Neerackal et al examined the efficacy of relaxation therapy alone, without cognitive therapy (n=60).⁴⁷ The results showed that after two months of practice, one week with a psychodermatologist, practicing the release-only relaxation technique on days one, three, and seven, followed by seven weeks using a voice recording, 70% of participants in the intervention group achieved a 50% improvement in the PASI score compared to 13% in the control group (p<0.03). Moreover, the intervention group showed significant improvements in the Dermatology Life Quality Index (DLQI) (p<0.01) and the Hospital Anxiety and Depression Scale (HADS) scores (p<0.01) compared to the control group.

Annika Hansen, MA

Annikahansen801@gmail.com

Dr. Lio reports being on the speaker’s bureau for AbbVie, Arcutis, Eli Lilly, Galderma, Hyphens Pharma, Incyte, La Roche-Posay/L’Oréal, Pfizer, Pierre-Fabre Dermatologie, Regeneron/Sanofi Genzyme, Verrica; reports consulting/advisory boards for Alphyn Biologics (stock options), AbbVie, Almirall, Amyris, Arcutis, ASLAN, Bristol-Myers Squibb, Burt’s Bees, Castle Biosciences, Codex Labs (stock options), Concerto Biosci (stock options), Dermavant, Eli Lilly, Galderma, Janssen, LEO Pharma, Lipidor, L’Oréal, Merck, Micreos, MyOR Diagnostics, Regeneron/Sanofi Genzyme, Sibel Health, Skinfix, Suneco Technologies (stock options), Theraplex, UCB, Unilever, Verdant Scientific (stock options), Verrica, Yobee Care (stock options). In addition, Dr. Lio has a patent pending for a Theraplex product with royalties paid and is a Board member and Scientific Advisory Committee Member emeritus of the National Eczema Association.

Annika Hansen has no conflicts of interest or relationships to disclose.

This research received no funding.