Managing stress

Philadelphia - Basic research has been building the case for decades of how stress negatively affects human health - from tumor genesis, to immune function, to skin barrier function - but clinical management of these interactions has lagged far behind.

"While there clearly is data to support their efficacy, we simply don't have the same body of controlled clinical trials to support the recommendations," Dr. Fried tells Dermatology Times.

He tells his patients, "Statistically speaking, stress management interventions tend to make your skin less irritable, tend to make your skin more responsive to traditional dermatologic therapies, and probably will increase the quality of your life in terms of your overall comfort level."

It is also likely to make you a more pleasant person for your family and coworkers.

Patient example

Dr. Fried uses the example of a patient, a middle-aged man who had had chronic psoriasis for decades, who came in for an office visit to see what was new in the treatment arsenal. The patient tried to maintain a stoic, macho front, but when gently questioned regarding the emotional impact, broke down and acknowledged that he was frequently angry, and his quality of life was horrible.

Dr. Fried treated the patient with Taclonex (calcipotriene/betamethasone dipropionate, Warner Chilcott), but also explained, "There is data to show that antidepressant medicines can help many people make their skin act in a more normal and modulated fashion. I don't think that people with psoriasis are crazy - I think their skin is a little nutty!

"The skin releases neuropeptides that perpetuate the psoriasis. I gave him 50 mg of Zoloft to augment his topical therapy and sent him on his way."

Dr. Fried continues, "I love this analogy of a nervous breakdown of the skin because it really taps into the notion that the skin is neurotic, not the owner. That is really important."

"But conversely, understanding that chronic skin disease, or any chronic stress can lead to depletion of neurotransmitters - serotonin, norepinephrine, dopamine - and the more these neurotransmitters get depleted, the more absolutely miserable and laborious life becomes. And that, in turn, becomes more stressful. Understanding that circle is really important for clinicians."

Re-engaging life

The patient with psoriasis came back six weeks later, accompanied by his wife. She took the bottle of Zoloft out of her purse and said, "'I don't know what is in this bottle, but it has given me back a husband and my kids back a father.'

"She went on to talk about how insidiously he had withdrawn over the past five to 10 years from things like coaching, intimacy and recreational activities."

Dr. Fried says, "I think all chronic disease can result in a very gradual robbing of activities." It sets up a negative feedback loop where the more removed patients get from the pleasures and interactions of life, the more stress they experience, the more miserable they get, the more miserable their disease gets, and the less energy is available to re-engage in life.

There is no financial incentive for industry to study nonpharmacologic interventions. Besides, "How do you teach mice to meditate?" he says.