Mind Body Practices for Psoriasis

Introduction

Psoriasis is a complex skin disease that may affect any part of the body, like the knees, elbows, and scalp. Also, can occur in the nails, joints [1,2] and mouth [3,4]. Both genders over a wide age range can be affected. Worldwide prevalence, white people are more commonly seen to be at risk than any other ethnicity, about 2% of the U.K. population are affected [5,6]. Psoriasis itself is not infectious [7], but some lesions may incur secondary infection, which may complicate treatment [8]. It is frequent in families, but may skip a generation, and many genes have been linked to it [9,10]. Many factors can to trigger the condition, including skin injury, a sore throat, chest infection, dental infections, sunburn, certain drug treatments, increased intake of alcohol [11], weather changes, and distress. Often it produces physical discomfort, such as itching, pain, and skin blemishes [12]. However, others find it no more than a slight irritation. Distress seems to be one an important factor [6,13-17]. Emotional trauma can trigger the disease [6,18,19].

Many people with psoriasis experience embarrassment in daily life, anxiety and mood disorders about the uncertainty of outcomes [1,20]. Emotional distress can cover a range of experiences. Because the condition is chronic, the time needed to treat the condition may be long [21] and there may be a fear of being unable to cover the cost of treatments [22-24]. Also, specific treatments may be needed, such as lithium for emotional disorders [25]. Some people feel shame in front of other people [26] and fear rejection. The latter is manifested by people with the condition avoiding public places, such as swimming pools, the beach, the gym, and restaurants [27] and being aware that many people are trying not to touch them, e.g. suffering rejection by barbers or at beauty salons [1]. They may be angry because they may feel discriminated against in employment. Depression at not being sexually attractive [28] may then lead to worry in a relationship about bearing children, because of the risk of genetic transmission [29].

The great variability of the disease, the unpredictability of its progress, and the way an individual’s personality can have an effect on its progression, illustrate the complexities involved in treating this disease [30] with important issues in patients mental health. Among the more important systemic implications than high levels of emotional stress, low levels of mental health result in consequent neglect of personal care as is often observed in the clinic, especially oral hygiene, leading to a serious condition of oral dysbiosis, which has relations with unpredictable and unfavorable dermatological outcomes observed in these patients. Complementary and alternative therapies (CAM) is not conventional, are widely used by patients suffering from psoriasis. Some of these complementary therapies are able to help people achieve some relief, allowing them to cope with their condition [31] specially Mind and Body Practices; however, in reality, we still do not have precise information on their effectiveness, efficacy, and safety, exactly the the scope of the present study. The USA’s National Institutes of Health (NIH) created the National Center for Complementary and Integrative Health (NIH/ NCCIH), which has determined criteria for the definition and classification of (CAMs). The term ‘complementary medicine’ refers only to the use of interventions in addition to conventional medicine. The term ‘alternative medicine’ refers to treatments used in place of conventional medicine, whereas the term ‘integrative medicine’ describes a combination of conventional medicine and complementary and integrative health (CAM) when there is evidence of effectiveness, efficiency, and safety [32]. The NCCAM/ NCCIH /NIH has divided CAM into the following categories:

a. Natural Products;

b. Mind and Body Practices; and

c. other CAM Practices with different modalities (e.g. movement therapies, traditional healers, manipulation of various energy fields, and whole medical systems such Traditional Chinese Medicine and Homeopathy) [32,33].

Mind / Body Practices utilize inborn evolutionary resources of the Central Nervous System (CNS) - neurophysiological, psychophysiological and cognitive resources - that can be “trained” and applied in a co-intervention regime to conventional resources, and also because they do not use any foreign chemical, or equipment, making them cost-effective interventions, easy to apply and generated low rates of adverse events. Among these tecniques are Meditation, Mindfulness, Hypnosis, Breathing Techniques, Relaxations Technique, EMDR, Virtual Reality Immersion, Biofeedback, Audio Visual Distractions and others. Mind/Body Practices can be used to reduce the effect of distress. Studies have shown that distress management has helped to increase the efficacy of treatments in many people with psoriasis [34], because distress appears to play an important part in a vicious cycle of interactions that lead to worsening psoriatic skin [35,36]. Although the intrinsic mechanisms of action of the Mind/Body Practices are not well understood, improvement in mental health may help [37] because when added to conventional treatments, results have been acceptable [32,38].

The concept of what CAM means is often completely dependent upon the cultural context of different countries. The definition of CAMs includes all such practices and ideas that are outside the domain of conventional medicine in most countries and considered by its users as preventing or treating illness, or promoting health or well-being [39]. It was made a Systematic Review according Cochrane’s Handbook, and the theme was reviewed the evidence for the possible potential benefits of complementary Interventions, classified according to the criteria of the National Center for Complementary and Integrative Health / NIH [32], which is aimed at treating chronic plaque psoriasis. It was found 1425 records from the database searches but only 9 was included for assessment all studies related to mind/body interventions were parallel and single centre RCTs [35,40-47]. Eight studies compared CAM with conventional medical practice [35,40,41,44-47] and three studies compared Complementary Medicine interventions against other Complementary Medicine interventions [35,42,43]. Only two studies used three or more groups [35,42]. Among the studies,there were a total of 379 participants. The number of participants in the studies varied from 11 to 169 [44,46]. The mean of the number of participants across studies was 29. All participants had light, moderate and heavy psoriasis with chronic conditions associated. The age varied between 18 to up 70 years old, with different ethnicity and in clinical settings, university hospitals, dermatology research centers, mental health care centers for behavioral medicine. The studies presented characteristics of participants reasonably similar to age (adults), gender (number of men and women), severity of the disease, presence of comorbidities and duration of the trials.

Although using the mind/body intervention, there were various types of intervention among included studies: [40] used Relaxation and Visualization Techniques; [42] used Imagery and Meditation Techniques; [44] used Biofeedback and Relaxation Techniques; [47] used the association psychologic interventions (Cognitive-Behavioral Stress-Management Techeniques, Relaxation Training, and Symptom Control Imagery Training); Fordham [41] and Kabat-Zinn [34] used Mindfulness Meditation Techniques;[46] used Hypnosis; [45] used Virtual Reality Immersion and Audiovisual Distraction Techniques; and [44] used a Telephone-Based Motivational Intervention. All included studies reported changes in disease status assessed by signs and symptoms although with different criteria. Five studies evaluated changes in participant status assessed by psychosocial changes, quality of life and treatment satisfaction using varied instruments [34,41,42,44,47]. There were no report of adverse events, or changes in conventional medicine interventions assessed by lower doses of drug, reduced ultraviolet light exposures, or increased intervals between relapses.

Risk of Bias Assessement

Included studies were assessed by Cochrane Risk of Bias Tool for Randomized Controlled Trials ( Higgins 2011) at different domains. One study used an adequate method for sequence generation and allocation concealment [44] and was classified as low risk of bias. Seven studies didn’t describe the method used for randomisation or allocation concealment and were classified as unclear risk of bias [34,40,42,43,45-47]. One study used an adequate method for sequence generation but did not describe the allocation concealment; hence was rated as low and unclear risk, respectively [41]. One study blinded the outcome assessors but did not blind the participants and personnel [42]; according to an assessment made, we considered the study as low risk of bias in the first case (performance bias) and high risk of bias in the second case (detection bias). Five studies didn’t describe information about blinding participants [34,40,41,43,44] and were considered as unclear risk of bias. Three studies didn’t use blinding [45-47] and were considered as high risk of bias. Five studies had few and balanced losses [42-46] and were classified as low risk of bias. Three studies had major and unbalanced losses of participants [34,41,47] and were classified as high risk of bias. Only one study [40] didn’t provide information about loss to follow up and was rated as unclear risk of attrition bias.

Eight studies provided the important and relevant outcomes [34,41-47] and were considered as low risk of bias. One study [40] didn’t provide enough information for adequate assessment and was classified as unclear risk of bias. Six studies [34,40,41,44,45,47] were classified as low risk of bias and one study [46] didn’t provide enough information for adequate assessment and was considered as unclear risk of bias. With different criteria among themselves, in two studies [42,43] the patients were selected according to some peculiar characteristics, which may generate bias, and were considered as high risk of bias. Among the more important systemic implications than high levels of emotional stress, low levels of mental health result in consequent neglect of personal care as is often observed in the clinic, especially oral hygiene, leading to a serious condition of oral dysbiosis, which has relations with unpredictable and unfavorable dermatological outcomes observed in these patients.

Among the more important systemic implications than high levels of emotional stress, low levels of mental health result in consequent neglect of personal care as is often observed in the clinic, especially oral hygiene, leading to a serious condition of oral dysbiosis, which has relations with unpredictable and unfavorable dermatological outcomes observed in these patients. The implications for practice for the Mind/Body Practices category, we found that the implementation of new therapeutical approaches in association with conventional procedures for improvement of mental health, especially for the category practices mind/body, is important for considering the impact of neuropsychic aspects of psoriasis patients beyond the distress, e.g. post-traumatic stress disorders, anxiety disorder due to a general medical condition, and so on even taking account of the difficulties for the establishment of specific diagnosis.

We believe further studies are needed to evaluate the effects and safety of complementary medicine, considering the impact of the observer-reported outcomes and patient-reported outcomes.

Among the various forms of intervention, this review found that there is evidence applicable to mind/body interventions related to motivational interventions (MI) due to the possibility of adjusting the intervention in a wide range of variability to cultural and ethnic aspects that make possible its viability, although important details on the reproducibility of the technique have not been provided by the authors.

Meditation intervention its also available but requires training which could represent some difficult specially for occidental cultures. In association with neuroscience studies, hypnosis is the intervention that requires more careful approach in order to turn safer the clinical procedures [48-51]. None of the trials identified in this review reported information about quality of life, harmful effects or even possible changes in conventional medicine interventions after using CAMs of the Mind/Body Practices type. The possible beneficial effect of interventions remains unclear although Mind/Body Practices seem to show better results when considering the number of sessions of treatment and the disease status. Future trials analysing important aspects of psoriasis and with better description of methodological aspects are necessary.of standardization processes in the synthesis of active chemicals principals and the wide variability of assessed substances from few studies results in low applicability and safety about the obtained evidence. However the component motivational for “change of life style” that is associated with CAMs approaches in general could be helpful and allows beneficial results as a strategy to elucidate participatory response of the patient in the therapeutic processes [47].

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