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Mind-Body Interventions for Psoriasis: Comparison
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Please note this is a comparison between Version 2 by Nora Tang and Version 1 by Ioan Alexandru.

Psoriasis is a chronic inflammatory disorder involving but not limited to the skin, with decisive immunological and genetic elements, upon which environmental factors may act. Conventional therapies include topical, systemic, and biologic agents. However, some of these therapies may trigger adverse effects of varying severity, at times may not be effective, or simply involve too high costs. For this reason, many patients resort to complementary and alternative medicine (CAM) to treat this pathology, with acupuncture, cupping, psychotherapy, and climatotherapy to name the most common procedures. In the following paragraphs, the CAM methods used for psoriasis are evaluated with respect to their efficacy, as shown in the English literature.

  • psoriasis
  • complementary and alternative medicine (CAM)
  • acupuncture
  • balneotherapy
  • climatotherapy
  • cupping therapy
  • psychotherapy

1. Psoriasis 

Psoriasis is a chronic inflammatory disorder that possesses decisive immunological and genetic elements, upon which several environmental factors may act, triggering the pathological cascade. Although it initially involves the skin, psoriasis leads to a substantial systemic impact, as well as a heavy psychological burden in many cases [1]. According to current data, it affects approximately 1–3% of the world population, presenting a first incidence peak between 15 and 20 years of age, followed by a secondary peak at 55 to 60 years [2]. In order to evaluate disease severity, various scores, such as the PASI (Psoriasis Area and Severity Index), or PGA × BSA (Physician Global Assessment and Body Surface Area) have been implemented, whereas the quality of life can be evaluated by the DLQI (Dermatology Life Quality Index) [3,4,5]. Presently, the PASI score is utilized for both the initial clinical evaluation of patients, and for their response to therapy. Although, until recently, PASI responses of 50 or 75 (denoting a 50% or 75% reduction in disease severity, respectively) were the primary aims for treatment, current methods strive for PASI 100, meaning a complete remission of cutaneous lesions [6,7,8]. These therapies include topically applied drugs such as dithranol, salicylic acid, corticosteroids, vitamin D analogues, or calcineurin inhibitors; phototherapy typically using either ultraviolet B (UVB), or a combination between psoralen and ultraviolet A (PUVA); systemic non-biologic therapies such as methotrexate (MTX), cyclosporin A, acitretin, apremilast, 6-thioguanine, or tofacitinib; and biologic agents that interfere with the pathological cascade of psoriasis near its outstart, these being TNF-α inhibitors (Adalimumab, Etanercept, Certolizumab, and Infliximab), the IL-12/23 inhibitor Ustekinumab, specific IL-23 inhibitors (Guselkumab, Risankizumab, and Tildrakizumab), and the IL-17 inhibitors (Brodalumab, Ixekizumab, and Secukinumab) [6,7,8,9,10]. The majority of modern therapies, whether focal, systemic or biologic, have a desired response of PASI 90 or 100, and are supported by a large volume of data as being regularly effective in ameliorating psoriasis. We, as practitioners, should always be informed and aware of recent developments, so that our selected treatment modality is optimal for each patient.

Psoriasis is a chronic inflammatory disorder that possesses decisive immunological and genetic elements, upon which several environmental factors may act, triggering the pathological cascade. Although it initially involves the skin, psoriasis leads to a substantial systemic impact, as well as a heavy psychological burden in many cases [1]. According to current data, it affects approximately 1–3% of the world population, presenting a first incidence peak between 15 and 20 years of age, followed by a secondary peak at 55 to 60 years [2]. In order to evaluate disease severity, various scores, such as the PASI (Psoriasis Area and Severity Index), or PGA × BSA (Physician Global Assessment and Body Surface Area) have been implemented, whereas the quality of life can be evaluated by the DLQI (Dermatology Life Quality Index) [3][4][5]. Presently, the PASI score is utilized for both the initial clinical evaluation of patients, and for their response to therapy. Although, until recently, PASI responses of 50 or 75 (denoting a 50% or 75% reduction in disease severity, respectively) were the primary aims for treatment, current methods strive for PASI 100, meaning a complete remission of cutaneous lesions [6][7][8]. These therapies include topically applied drugs such as dithranol, salicylic acid, corticosteroids, vitamin D analogues, or calcineurin inhibitors; phototherapy typically using either ultraviolet B (UVB), or a combination between psoralen and ultraviolet A (PUVA); systemic non-biologic therapies such as methotrexate (MTX), cyclosporin A, acitretin, apremilast, 6-thioguanine, or tofacitinib; and biologic agents that interfere with the pathological cascade of psoriasis near its outstart, these being TNF-α inhibitors (Adalimumab, Etanercept, Certolizumab, and Infliximab), the IL-12/23 inhibitor Ustekinumab, specific IL-23 inhibitors (Guselkumab, Risankizumab, and Tildrakizumab), and the IL-17 inhibitors (Brodalumab, Ixekizumab, and Secukinumab) [6][7][8][9][10]. The majority of modern therapies, whether focal, systemic or biologic, have a desired response of PASI 90 or 100, and are supported by a large volume of data as being regularly effective in ameliorating psoriasis. We, as practitioners, should always be informed and aware of recent developments, so that our selected treatment modality is optimal for each patient.

As conventional therapies are not always efficient in psoriasis, are high cost, and are sometimes associated with undesirable side effects, complementary and alternative medicine (CAM) may offer a safe and generally inexpensive substitute for some patients. Complementary medicine blends these approaches with conventional treatment, while alternative medicine is utilized instead of mainstream therapies. These are split into two groups: mind–body interventions (acupuncture, cupping, and meditation) and natural products, incorporating herbs, vitamins, and dietary supplements [11,12]. It is estimated that more than half of the patients with psoriasis seek CAM because of their dissatisfaction with the effects of conventional treatment methods [11,12,13], despite the fact that, until recently, CAM has been regarded as a non-evidence-based practice [13]. Hereafter, we present a systematic review of the studies on mind and body interventions performed for psoriasis that are available in the English literature.

As conventional therapies are not always efficient in psoriasis, are high cost, and are sometimes associated with undesirable side effects, complementary and alternative medicine (CAM) may offer a safe and generally inexpensive substitute for some patients. Complementary medicine blends these approaches with conventional treatment, while alternative medicine is utilized instead of mainstream therapies. These are split into two groups: mind–body interventions (acupuncture, cupping, and meditation) and natural products, incorporating herbs, vitamins, and dietary supplements [11][12]. It is estimated that more than half of the patients with psoriasis seek CAM because of their dissatisfaction with the effects of conventional treatment methods [11][12][13], despite the fact that, until recently, CAM has been regarded as a non-evidence-based practice [13]. Hereafter, we present a systematic review of the studies on mind and body interventions performed for psoriasis that are available in the English literature.

2. Acupuncture

Acupuncture is a well-known Traditional Chinese Medicine (TCM) practice that has been successfully utilized for more than three millennia. It is generally considered a safe approach, with few side-effects, being accepted across the world for numerous ailments [96]. The exact origin of acupuncture is unknown, and a few styles have been defined, for example needling, moxibustion, cupping and acupressure. It is important to note that acupuncture is customarily used in combination with other therapeutic approaches of TCM, such as herbal remedies. In needling for psoriasis, there are several acupuncture points available in which, as the name implies, disposable needles are inserted into the skin to stimulate blood flow and reduce local inflammation though an as-of-yet imprecise mechanism [97]. A recent study performed on mice discovered that electroacupuncture, needling and fire needling was correlated with a lower local CD3+ T-cell population, as well as lower levels of substance P, neurokinin A, IL-17A, IL-1B, and IL-23p40 [96]. Acupoint stimulation should be implemented for a period of at least of six weeks in order to achieve therapeutic effect [98,99]. Some authors have reported a decreased recurrence rate of plaque psoriasis after acupuncture when compared to conventional medicine [96]. Still, not all authors agree on the efficacy of acupuncture, as data are scarce and, at least until recently, not always easily accessible to the researching community [98]. A recent meta-analysis on the use of acupuncture in psoriasis comprising 13 RCTs and a total of 1060 participants has shown that acupoint stimulation had a superior effect to the placebo (non-acupoint stimulation) [99]. However, the trials included in this meta-analysis clashed regarding the specific acupoints used, the exact number of stimulated points, as well as duration of acupuncture sessions. Furthermore, adequate blinding was realized in only two of the studies, thus making a proper comparison difficult. Nevertheless, according to the findings of these analyses, the acupuncture appears to provide benefits in the treatment of psoriasis irrespective of the stage of the disease, although it is challenging to ascertain the most advantageous technique [12,100].

Acupuncture is a well-known Traditional Chinese Medicine (TCM) practice that has been successfully utilized for more than three millennia. It is generally considered a safe approach, with few side-effects, being accepted across the world for numerous ailments [14]. The exact origin of acupuncture is unknown, and a few styles have been defined, for example needling, moxibustion, cupping and acupressure. It is important to note that acupuncture is customarily used in combination with other therapeutic approaches of TCM, such as herbal remedies. In needling for psoriasis, there are several acupuncture points available in which, as the name implies, disposable needles are inserted into the skin to stimulate blood flow and reduce local inflammation though an as-of-yet imprecise mechanism [15]. A recent study performed on mice discovered that electroacupuncture, needling and fire needling was correlated with a lower local CD3+ T-cell population, as well as lower levels of substance P, neurokinin A, IL-17A, IL-1B, and IL-23p40 [14]. Acupoint stimulation should be implemented for a period of at least of six weeks in order to achieve therapeutic effect [16][17]. Some authors have reported a decreased recurrence rate of plaque psoriasis after acupuncture when compared to conventional medicine [14]. Still, not all authors agree on the efficacy of acupuncture, as data are scarce and, at least until recently, not always easily accessible to the researching community [16]. A recent meta-analysis on the use of acupuncture in psoriasis comprising 13 RCTs and a total of 1060 participants has shown that acupoint stimulation had a superior effect to the placebo (non-acupoint stimulation) [17]. However, the trials included in this meta-analysis clashed regarding the specific acupoints used, the exact number of stimulated points, as well as duration of acupuncture sessions. Furthermore, adequate blinding was realized in only two of the studies, thus making a proper comparison difficult. Nevertheless, according to the findings of these analyses, the acupuncture appears to provide benefits in the treatment of psoriasis irrespective of the stage of the disease, although it is challenging to ascertain the most advantageous technique [12][18].

Two RCTs did not show a significant improvement in PASI score when compared to a control procedure, either sham acupuncture [28], or oral Huoxue Jiedu Decoction and Vaseline cream alone [29], although the latter did demonstrate an amelioration in the quality of life. A third RCT revealed a significant improvement in PASI within both the treatment with auricular therapy plus optimized Yinxieling formula and control groups, yet more so in the former, whereas DLQI scores presented a non-significant decrease in these groups [30]. According to Jorge et al., ear acupuncture managed to result in the complete disappearance of psoriasis in five of their seven patients, while the remaining two presented marked recovery [31]. A retrospective study on 61 patients demonstrated moderate improvement in psoriasis patients, on average [19], while another such account of 80 patients observed a 91.3% treatment effectiveness, with 41 cured, 18 markedly improved, and 14 individuals improved [20]. However, no standard evaluation score was provided for accurate comparison. We identified four case reports totaling five patients that benefitted from clinical improvement after acupuncture [32,33,34,35], one even demonstrating the complete disappearance of lesions [32]. Two of these reports did not provide a severity score, and as such a more objective evaluation could not be performed [34,35]. There were also two case reports of patients presenting with Koebner phenomenon after acupuncture [36,37]. The Koebner phenomenon, as defined by the German dermatologist Heinrich Koebner (1838–1904), denotes the manifestation of isomorphic lesions at the sites of a cutaneous injury in an otherwise healthy skin [38,101]. It can occur in several dermatological afflictions, most commonly psoriasis, lichen planus, and vitiligo. Therefore, it is likely that interventions that involve damaging the dermis, such as acupuncture and cupping, may trigger this type of lesion in psoriatic patients.

Two RCTs did not show a significant improvement in PASI score when compared to a control procedure, either sham acupuncture [19], or oral Huoxue Jiedu Decoction and Vaseline cream alone [20], although the latter did demonstrate an amelioration in the quality of life. A third RCT revealed a significant improvement in PASI within both the treatment with auricular therapy plus optimized Yinxieling formula and control groups, yet more so in the former, whereas DLQI scores presented a non-significant decrease in these groups [21]. According to Jorge et al., ear acupuncture managed to result in the complete disappearance of psoriasis in five of their seven patients, while the remaining two presented marked recovery [22]. A retrospective study on 61 patients demonstrated moderate improvement in psoriasis patients, on average [23], while another such account of 80 patients observed a 91.3% treatment effectiveness, with 41 cured, 18 markedly improved, and 14 individuals improved [24]. However, no standard evaluation score was provided for accurate comparison. We identified four case reports totaling five patients that benefitted from clinical improvement after acupuncture [25][26][27][28], one even demonstrating the complete disappearance of lesions [25]. Two of these reports did not provide a severity score, and as such a more objective evaluation could not be performed [27][28]. There were also two case reports of patients presenting with Koebner phenomenon after acupuncture [29][30]. The Koebner phenomenon, as defined by the German dermatologist Heinrich Koebner (1838–1904), denotes the manifestation of isomorphic lesions at the sites of a cutaneous injury in an otherwise healthy skin [31][32]. It can occur in several dermatological afflictions, most commonly psoriasis, lichen planus, and vitiligo. Therefore, it is likely that interventions that involve damaging the dermis, such as acupuncture and cupping, may trigger this type of lesion in psoriatic patients.

Despite our rigorous search in this field of CAM, reference cross-check did not yield several of the cited articles. As such, we could not discuss some of the studies included in other reviews and meta-analyses. Regarding the use of acupuncture and its associated procedures, the majority of reports show a positive effect on the amelioration of psoriatic plaques. Several articles written in Chinese and not readily accessible to Western readers may provide further insight into the benefits of acupuncture in psoriasis. As of the writing of this review, a number of trials on the benefits of various acupuncture techniques in psoriasis are currently ongoing [97,102]. The reason for including acupuncture in our review of CAM methods for this disease is primarily because of its popular use in China and other Eastern countries.

Despite our rigorous search in this field of CAM, reference cross-check did not yield several of the cited articles. As such, we could not discuss some of the studies included in other reviews and meta-analyses. Regarding the use of acupuncture and its associated procedures, the majority of reports show a positive effect on the amelioration of psoriatic plaques. Several articles written in Chinese and not readily accessible to Western readers may provide further insight into the benefits of acupuncture in psoriasis. As of the writing of this review, a number of trials on the benefits of various acupuncture techniques in psoriasis are currently ongoing [15][33]. The reason for including acupuncture in our review of CAM methods for this disease is primarily because of its popular use in China and other Eastern countries.

3. Cupping Therapy

Cupping therapy is an ancient treatment method likened to acupuncture, also employed for various diseases. It has been described since antiquity, from the ancient Egyptians to the Chinese Han Dynasty, also being used in the times of Hippocrates and even to the early Islamic period [103,104,105]. Two types of cupping methods exist, namely dry and wet, also known as Hijama (or Hijamah) in Egypt and Arabic countries [39,40,41,42,43,44,106]. This treatment method creates a vacuum by placing glass suction cups directly on the skin of various body parts, mostly on the back, shoulders, buttocks or limbs [15,106]. The difference between dry and wet cupping stands in that the latter requires a skin incision either before or after performing the suctioning itself. Thus, it is believed that impurities in the blood and tissues can be drawn out, instead of simply transferred from one body site to another. The moving cupping method is a unique dry type of cupping that involves the application of lubricant (such as Vaseline) either to the treated body part or to the mouth of the glass cup and adsorbing the cup to the desired area. The physician then moves the glass cup manually across the skin in all directions while applying light force, thus producing flushing, heightened tissue blood flow, and in some cases even ecchymosis in the chosen treatment area [103]. This causes a local accumulation of antioxidant and anti-inflammatory products such as heme-oxigenase-1, carbon monoxide, biliverdin, and bilirubin, which also have antiproliferative and neruomodulatory effects [104]. Additionally, it was shown that cupping induces vascular endothelial growth factor (VEGF)-A expression in keratinocytes via the nitric oxide (NO)-mediated activation of hypoxia inducible factor (HIF)-1, thereby promoting angiogenesis [105]. It is thought that this method has the ability to increase skin tolerance and significantly improve its barrier function [104,105] and has already proven effective in the management of pain-related diseases, such as chronic low back pain or osteoarthritis [103]. A multicenter RCT trial is currently underway in China, aiming to determine the efficacy of moving cupping in the treatment of plaque psoriasis [103].

Cupping therapy is an ancient treatment method likened to acupuncture, also employed for various diseases. It has been described since antiquity, from the ancient Egyptians to the Chinese Han Dynasty, also being used in the times of Hippocrates and even to the early Islamic period [34][35][36]. Two types of cupping methods exist, namely dry and wet, also known as Hijama (or Hijamah) in Egypt and Arabic countries [37][38][39][40][41][42][43]. This treatment method creates a vacuum by placing glass suction cups directly on the skin of various body parts, mostly on the back, shoulders, buttocks or limbs [44][43]. The difference between dry and wet cupping stands in that the latter requires a skin incision either before or after performing the suctioning itself. Thus, it is believed that impurities in the blood and tissues can be drawn out, instead of simply transferred from one body site to another. The moving cupping method is a unique dry type of cupping that involves the application of lubricant (such as Vaseline) either to the treated body part or to the mouth of the glass cup and adsorbing the cup to the desired area. The physician then moves the glass cup manually across the skin in all directions while applying light force, thus producing flushing, heightened tissue blood flow, and in some cases even ecchymosis in the chosen treatment area [34]. This causes a local accumulation of antioxidant and anti-inflammatory products such as heme-oxigenase-1, carbon monoxide, biliverdin, and bilirubin, which also have antiproliferative and neruomodulatory effects [35]. Additionally, it was shown that cupping induces vascular endothelial growth factor (VEGF)-A expression in keratinocytes via the nitric oxide (NO)-mediated activation of hypoxia inducible factor (HIF)-1, thereby promoting angiogenesis [36]. It is thought that this method has the ability to increase skin tolerance and significantly improve its barrier function [35][36] and has already proven effective in the management of pain-related diseases, such as chronic low back pain or osteoarthritis [34]. A multicenter RCT trial is currently underway in China, aiming to determine the efficacy of moving cupping in the treatment of plaque psoriasis [34].

However, current evidence in the English literature is far from encouraging. The study of El-Domyati et al., which enrolled 50 patients with various dermatoses, including eight with psoriasis vulgaris, failed to show any improvement in psoriatic patients [14]. Moreover, three of these patients demonstrated Koebner phenomenon at the site of cupping, leading to the termination of therapy. Contrarily, all individuals with chronic idiopathic urticaria, 10 out of 11 of acne vulgaris patients (90.9%), and two out of nine with atopic dermatitis (22.2%), showed clinical improvement, whereas none of the patients with vitiligo presented any changes. In the report by Sharquie et al., 24 patients presented with on-site Koebner phenomenon after undergoing cupping, 16 (66.7%) of whom had been previously diagnosed with psoriasis [15]. Six other case reports demonstrated the Koebner phenomenon strictly on the regions receiving cupping therapy [40,41,42,43,44], and to the best of our knowledge, only the patient described by Malik et al. benefited from a reduction in disease severity after wet cupping [39]. Interestingly, only male patients were included in these reports, yet no explanation could be given for this reason. While we are aware that the Chinese literature holds several studies pertaining to the beneficial effects of cupping in psoriasis [107], these were either inaccessible to us or did not have an English full-text version. Thus, as it stands, there is little evidence in the Western literature to support cupping therapy as an effective or beneficial CAM management in psoriasis.

However, current evidence in the English literature is far from encouraging. The study of El-Domyati et al., which enrolled 50 patients with various dermatoses, including eight with psoriasis vulgaris, failed to show any improvement in psoriatic patients [45]. Moreover, three of these patients demonstrated Koebner phenomenon at the site of cupping, leading to the termination of therapy. Contrarily, all individuals with chronic idiopathic urticaria, 10 out of 11 of acne vulgaris patients (90.9%), and two out of nine with atopic dermatitis (22.2%), showed clinical improvement, whereas none of the patients with vitiligo presented any changes. In the report by Sharquie et al., 24 patients presented with on-site Koebner phenomenon after undergoing cupping, 16 (66.7%) of whom had been previously diagnosed with psoriasis [44]. Six other case reports demonstrated the Koebner phenomenon strictly on the regions receiving cupping therapy [38][39][40][41][42], and to the best of our knowledge, only the patient described by Malik et al. benefited from a reduction in disease severity after wet cupping [37]. Interestingly, only male patients were included in these reports, yet no explanation could be given for this reason. While we are aware that the Chinese literature holds several studies pertaining to the beneficial effects of cupping in psoriasis [46], these were either inaccessible to us or did not have an English full-text version. Thus, as it stands, there is little evidence in the Western literature to support cupping therapy as an effective or beneficial CAM management in psoriasis.

4. Psychotherapy, Stress Management and Meditation

Psoriasis is known to cause significant psychological distress, depression, feelings of stigmatization, and reduced health-related quality of life [108]. Moreover, stress has been recognized as a trigger factor in both the appearance and exacerbation of psoriasis, aggravating the cutaneous manifestations of the disease in more than half of the patients. Psychotherapy has been studied in several trials and individual case reports, with the results being promising [45,46,47], even as early as one millennium ago [48], but sometimes with little difference from the control groups receiving usual care or no treatment at all [16,49,50]. As of yet, the mechanism through which stress initiates or worsens this disease is unclear; however, some studies have shown marked improvement in the clinical state after psychotherapy. An RCT comparing phototherapy with and without listening to mindfulness-based stress reduction recordings during treatment sessions revealed that clinical improvement was achieved markedly faster in the meditation group [51]. The beneficial effects of hypnosis in psoriasis were evaluated in several case reports [52,53,54], as well as an RCT of 11 patients, which suggested that easily hypnotizable patients showed greater improvements in disease control [55]. Guided imagery, meditation, and cognitive-behavioral stress management was shown to offer moderate but statistically significant improvement when PASI, total sign score (TSS), and Doppler blood flow to psoriatic plaques were assessed [50]. Although the same trial did not yield a significant difference in PASI scores between the treatment group and the control group that did not receive any form of therapy. Meditation with or without imagery produced a marked clinical amelioration compared to no therapy at all, yet the mentioned study was limited by the small number of patients included [56]. The same effect can be observed when assessing Medical Resonance Therapy Music with standard care against standard care alone, although no statistical significance was specified [57].

Psoriasis is known to cause significant psychological distress, depression, feelings of stigmatization, and reduced health-related quality of life [47]. Moreover, stress has been recognized as a trigger factor in both the appearance and exacerbation of psoriasis, aggravating the cutaneous manifestations of the disease in more than half of the patients. Psychotherapy has been studied in several trials and individual case reports, with the results being promising [48][49][50], even as early as one millennium ago [51], but sometimes with little difference from the control groups receiving usual care or no treatment at all [52][53][54]. As of yet, the mechanism through which stress initiates or worsens this disease is unclear; however, some studies have shown marked improvement in the clinical state after psychotherapy. An RCT comparing phototherapy with and without listening to mindfulness-based stress reduction recordings during treatment sessions revealed that clinical improvement was achieved markedly faster in the meditation group [55]. The beneficial effects of hypnosis in psoriasis were evaluated in several case reports [56][57][58], as well as an RCT of 11 patients, which suggested that easily hypnotizable patients showed greater improvements in disease control [59]. Guided imagery, meditation, and cognitive-behavioral stress management was shown to offer moderate but statistically significant improvement when PASI, total sign score (TSS), and Doppler blood flow to psoriatic plaques were assessed [54]. Although the same trial did not yield a significant difference in PASI scores between the treatment group and the control group that did not receive any form of therapy. Meditation with or without imagery produced a marked clinical amelioration compared to no therapy at all, yet the mentioned study was limited by the small number of patients included [60]. The same effect can be observed when assessing Medical Resonance Therapy Music with standard care against standard care alone, although no statistical significance was specified [61].

In one prospective RCT of 40 patients, written emotional disclosure combined with UVB therapy led to a better clinical result and a longer period of time than the standard UVB treatment [58]. Nonetheless, two other RCTs on written emotional disclosure did show improvement in both treatment and control groups with control writing intervention (focusing on activities of the previous day) [59] and educational intervention, respectively [60], yet no significant difference between treatment and control groups was observed. Mindfulness-based cognitive therapy MBCT and its variants, mindfulness-based self-compassion therapy (MBSCT), and self-help MBSCT (MBSCT-SH), have yielded positive results, though mixed in comparison with treatment as usual [61,62]. Similarly, internet-based cognitive behavioral therapy (ICBT) managed to improve physical functioning and diminish the impact of psoriasis on everyday activities in patients presenting a psychological risk profile, and also enhanced and maintained psychological wellbeing [63,64]. Based on the RCT by Bundy et al., a web-based online electronic Targeted Intervention for Psoriasis (eTIPs), also a form of cognitive-behavioral therapy, did not achieve a significantly different result when compared to standard care, yet, as the authors mentioned, the results were constrained by a large quantum of missing data [65]. Support group therapy may have the benefit of both clinical improvement and enhancing the patients’ knowledge and ability to cope with the disease [21,66]. As stated by Piaserico et al., biofeedback and cognitive-behavioral therapy and UVB therapy resulted in a significant reduction in psoriasis severity, as quantified by PASI, in addition to a higher percentage of patients achieving PASI 75 response at 8 weeks in comparison to patients receiving only UVB therapy [67]. Thermal biofeedback led to the complete disappearance of all previously existing psoriasis lesions, as well as the disappearance without scarring of any new ones occurring during treatment in one reported case [68]. In another similar description, thermal biofeedback in conjunction with supportive psychotherapy managed to markedly ameliorate dermatological signs [69]. Although promising, these studies are few in number, are small in size, and some of them are steadily becoming outdated. Furthermore, despite no obvious risk tied to meditation or hypnotherapy, some argue that there is little evidence to support them as financially justifiable treatment methods [109]. Nevertheless, this may prove an advantageous complementary treatment method of psoriasis in the future.

In one prospective RCT of 40 patients, written emotional disclosure combined with UVB therapy led to a better clinical result and a longer period of time than the standard UVB treatment [62]. Nonetheless, two other RCTs on written emotional disclosure did show improvement in both treatment and control groups with control writing intervention (focusing on activities of the previous day) [63] and educational intervention, respectively [64], yet no significant difference between treatment and control groups was observed. Mindfulness-based cognitive therapy MBCT and its variants, mindfulness-based self-compassion therapy (MBSCT), and self-help MBSCT (MBSCT-SH), have yielded positive results, though mixed in comparison with treatment as usual [65][66]. Similarly, internet-based cognitive behavioral therapy (ICBT) managed to improve physical functioning and diminish the impact of psoriasis on everyday activities in patients presenting a psychological risk profile, and also enhanced and maintained psychological wellbeing [67][68]. Based on the RCT by Bundy et al., a web-based online electronic Targeted Intervention for Psoriasis (eTIPs), also a form of cognitive-behavioral therapy, did not achieve a significantly different result when compared to standard care, yet, as the authors mentioned, the results were constrained by a large quantum of missing data [69]. Support group therapy may have the benefit of both clinical improvement and enhancing the patients’ knowledge and ability to cope with the disease [70][71]. As stated by Piaserico et al., biofeedback and cognitive-behavioral therapy and UVB therapy resulted in a significant reduction in psoriasis severity, as quantified by PASI, in addition to a higher percentage of patients achieving PASI 75 response at 8 weeks in comparison to patients receiving only UVB therapy [72]. Thermal biofeedback led to the complete disappearance of all previously existing psoriasis lesions, as well as the disappearance without scarring of any new ones occurring during treatment in one reported case [73]. In another similar description, thermal biofeedback in conjunction with supportive psychotherapy managed to markedly ameliorate dermatological signs [74]. Although promising, these studies are few in number, are small in size, and some of them are steadily becoming outdated. Furthermore, despite no obvious risk tied to meditation or hypnotherapy, some argue that there is little evidence to support them as financially justifiable treatment methods [75]. Nevertheless, this may prove an advantageous complementary treatment method of psoriasis in the future.

Considering that psoriasis is stress-mediated, it stands to reason that psychotherapy and interventions that focus on stress reduction might be beneficial for these patients. The results of the majority of studies are promising; however, not conclusive. The remarkable variation in therapy length may be due to the heterogeneity of therapies included in this group, as well as individual characteristics and requirements of each patient. It is important to notice that these therapies are mostly used in conjunction with treatment as usual and should not be viewed as a replacement to standard care.

5. Balneotherapy and Climatotherapy

Balneotherapy and Climatotherapy denote already established CAM treatment methods in moderate-to-severe psoriasis, having been proven effective in the short-term clearing and remission induction across several studies [18,70,110,111]. The most common destination for climate therapy is the Dead Sea, with 18 out of the total of 34 studies included having been conducted there [17,18,25,70,71,72,73,74,75,76,77,78,79,80,81,82,83,84]. This treatment method implies spending several weeks at the Dead Sea, bathing in its waters and lying in the sun. The Dead Sea is located on the lowest point on the landmasses of Earth, at approximately 400 m below sea level, possessing the highest concentration of salt of any natural body of water. It boasts exceptional climatic properties, which are beneficial for a wide variety dermatological conditions, specifically for psoriasis. The efficacy of Dead Sea climatotherapy is probably the result of a mixture between the anti-inflammatory effects of stress reduction, the anti-proliferative and keratolytic effects of local minerals, and the particular UV characteristics at that latitude [18,70,110,111]. More precisely, UVA and longer wavelength beneficial UVB rays are found at the site of the Dead Sea, whereas shorter erythrogenic UVB rays are generally filtered [11]. Severe adverse events following this type of therapy are rare. According to David et al., climatotherapy at the Dead Sea for psoriasis patients was more frequently associated with elastosis, solar lentigines, poikiloderma, and facial wrinkles than in control patients, also displaying an exposure-dependent response [18]. Additionally, the same study concluded that Dead Sea climate therapy was not correlated with a heightened risk of developing melanoma or nonmelanoma skin cancer in these patients. Another retrospective study concluded that some of these patients present an increase in epidermal pigmentation when compared to pretreatment biopsy specimens, although there were no epidermal dystrophies or melanocytic atypia reported [83]. Contrariwise, consistent with the findings by Frentz et al., the overall risk of skin malignancies (especially non-melanoma skin cancer) in patients undergoing this therapy was higher than estimated for the general population [75]. The body surface distribution of cutaneous cancers favored multiple sites, and typically affected younger individuals, especially women. Reoccurrence of psoriatic lesions at previous sites can occur after a given period of time following Dead Sea climate therapy [73].

Balneotherapy and Climatotherapy denote already established CAM treatment methods in moderate-to-severe psoriasis, having been proven effective in the short-term clearing and remission induction across several studies [76][77][78][79]. The most common destination for climate therapy is the Dead Sea, with 18 out of the total of 34 studies included having been conducted there [80][76][81][77][82][83][84][85][86][87][88][89][90][91][92][93][94][95]. This treatment method implies spending several weeks at the Dead Sea, bathing in its waters and lying in the sun. The Dead Sea is located on the lowest point on the landmasses of Earth, at approximately 400 m below sea level, possessing the highest concentration of salt of any natural body of water. It boasts exceptional climatic properties, which are beneficial for a wide variety dermatological conditions, specifically for psoriasis. The efficacy of Dead Sea climatotherapy is probably the result of a mixture between the anti-inflammatory effects of stress reduction, the anti-proliferative and keratolytic effects of local minerals, and the particular UV characteristics at that latitude [76][77][78][79]. More precisely, UVA and longer wavelength beneficial UVB rays are found at the site of the Dead Sea, whereas shorter erythrogenic UVB rays are generally filtered [11]. Severe adverse events following this type of therapy are rare. According to David et al., climatotherapy at the Dead Sea for psoriasis patients was more frequently associated with elastosis, solar lentigines, poikiloderma, and facial wrinkles than in control patients, also displaying an exposure-dependent response [76]. Additionally, the same study concluded that Dead Sea climate therapy was not correlated with a heightened risk of developing melanoma or nonmelanoma skin cancer in these patients. Another retrospective study concluded that some of these patients present an increase in epidermal pigmentation when compared to pretreatment biopsy specimens, although there were no epidermal dystrophies or melanocytic atypia reported [94]. Contrariwise, consistent with the findings by Frentz et al., the overall risk of skin malignancies (especially non-melanoma skin cancer) in patients undergoing this therapy was higher than estimated for the general population [86]. The body surface distribution of cutaneous cancers favored multiple sites, and typically affected younger individuals, especially women. Reoccurrence of psoriatic lesions at previous sites can occur after a given period of time following Dead Sea climate therapy [84].

Several prospective cohorts demonstrated a significant decrease in PASI scores in patients following Dead Sea climatotherapy, the majority of individuals achieving a PASI 75 response or more [25,70,72,74,77,79,84]. Furthermore, some of these studies also showed an improved quality of life, as measured by DLQI [72,84]. Both Kushelevski and Harari reported a higher clearance rate of lesions in patients with early-onset psoriasis and those with a longer duration of the disease [76,77,78,81]. Currently, the influence of the number of previous climate therapy stays on clinical amelioration has not been definitively established [78,84]. Another ambiguity is the daily exposure to sun needed to effectively treat psoriasis, on one hand Even-Paz et al. stating that 3 h divided in two equal sessions from 9 AM and 2 PM were sufficient when compared to 4.5 and 6 h per day [74], and on the other, Harari and Shani reporting that the best results were obtained in patients staying in the sun at least 7 h daily [74]. Patients additionally receiving systemic therapies such as methotrexate might not demonstrate better results than those undergoing climate therapy alone [71].

Several prospective cohorts demonstrated a significant decrease in PASI scores in patients following Dead Sea climatotherapy, the majority of individuals achieving a PASI 75 response or more [81][77][83][85][88][90][95]. Furthermore, some of these studies also showed an improved quality of life, as measured by DLQI [83][95]. Both Kushelevski and Harari reported a higher clearance rate of lesions in patients with early-onset psoriasis and those with a longer duration of the disease [87][88][89][92]. Currently, the influence of the number of previous climate therapy stays on clinical amelioration has not been definitively established [89][95]. Another ambiguity is the daily exposure to sun needed to effectively treat psoriasis, on one hand Even-Paz et al. stating that 3 h divided in two equal sessions from 9 AM and 2 PM were sufficient when compared to 4.5 and 6 h per day [85], and on the other, Harari and Shani reporting that the best results were obtained in patients staying in the sun at least 7 h daily [85]. Patients additionally receiving systemic therapies such as methotrexate might not demonstrate better results than those undergoing climate therapy alone [82].

Other locations that have climatotherapeutic or balneotherapeutic (bathing in hot springs) effects are in the Black Sea, Nord Sea, Baltic Sea, Canary Islands, Kangal Hot Springs in Turkey, or the Blue Lagoon in Iceland, but the evidence regarding each of these sites is lacking when compared to the Dead Sea [11,18,70,110,111]. Balneotherapy alone or in combination with standard treatment or phototherapy has repeatedly proven to be more effective than standard treatment alone [23,85,86,87,88,89]. Geothermal sea water balneotherapy and narrowband UVB (NB-UVB) light therapy is apparently more effective in attaining clinical and histological amelioration, results in longer remission time and allows for lower UV doses than NB-UVB therapy alone [21]. Gran Canaria climate therapy has also shown potential in decreasing psoriasis severity, as well as promoting mental health and improving health-related emotional distress [25,26,90]. Balneotherapy in the selenium-rich waters of La Roche-Posay also has the potential of reducing severity [91,92]. Moreover, as concluded in the study of skin microbiome composition in these patients, the Xanthomonadaceae family associated with Proteobacteria phylum, and recognized as keratolytic, was linked to clinical amelioration after a 3-week balneotherapy treatment [91].

Other locations that have climatotherapeutic or balneotherapeutic (bathing in hot springs) effects are in the Black Sea, Nord Sea, Baltic Sea, Canary Islands, Kangal Hot Springs in Turkey, or the Blue Lagoon in Iceland, but the evidence regarding each of these sites is lacking when compared to the Dead Sea [11][76][77][78][79]. Balneotherapy alone or in combination with standard treatment or phototherapy has repeatedly proven to be more effective than standard treatment alone [96][97][98][99][100][101]. Geothermal sea water balneotherapy and narrowband UVB (NB-UVB) light therapy is apparently more effective in attaining clinical and histological amelioration, results in longer remission time and allows for lower UV doses than NB-UVB therapy alone [70]. Gran Canaria climate therapy has also shown potential in decreasing psoriasis severity, as well as promoting mental health and improving health-related emotional distress [81][102][103]. Balneotherapy in the selenium-rich waters of La Roche-Posay also has the potential of reducing severity [104][105]. Moreover, as concluded in the study of skin microbiome composition in these patients, the Xanthomonadaceae family associated with Proteobacteria phylum, and recognized as keratolytic, was linked to clinical amelioration after a 3-week balneotherapy treatment [104].

Consolidated balneotherapy supplemented with Chinese herbal medicine led to a notably longer remission time than the unconsolidated form, which was stopped after PASI dropped to 1.8–2.0 [93]. Leopoldine spa water balneotherapy showed a marked and statistically significant improvement when compared to double-distilled tap water treatment on the opposite arms of the same patients [94]. However, in another similar study, no significant difference was noticed between highly concentrated salt water and simple tap water balneotherapy [24]. Liman peloid application and bath therapy was also associated with benefits to severity score, time to recurrence, and a reduction in topical drug use than clay peloid and tap water [95].

Consolidated balneotherapy supplemented with Chinese herbal medicine led to a notably longer remission time than the unconsolidated form, which was stopped after PASI dropped to 1.8–2.0 [106]. Leopoldine spa water balneotherapy showed a marked and statistically significant improvement when compared to double-distilled tap water treatment on the opposite arms of the same patients [107]. However, in another similar study, no significant difference was noticed between highly concentrated salt water and simple tap water balneotherapy [108]. Liman peloid application and bath therapy was also associated with benefits to severity score, time to recurrence, and a reduction in topical drug use than clay peloid and tap water [109].

This treatment form presented the most homogeneous treatment length, usually at around 3–4 weeks, although extremes of 6 days and 8 months were also noticed. Additionally, the average age of patients following these therapies was higher than for the other treatments, though this could be a simple incidental observation. The evidence on hand supports balneotherapy and climate therapy as complementary therapies for psoriasis, capable of even inducing remission. A special recommendation should be given to patients with early-onset psoriasis and those with a longer disease duration, while caution must be taken for immunocompromised individuals or those with a history of skin malignancies.

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