Mindfulness and the Mediterranean diet as alternative therapies in ambulatory care of psoriasis

INTRODUCTION

Psoriasis is a multifactorial autoimmune disease characterized by inflammation and proliferation of spherical papules and plaques on the skin, the skin lesions are erythematous and covered with silvery scales that flake off at an accelerated rate. As psoriasis develops, there is a continuous rise in the proinflammatory level of cytokines, especially interleukins (IL) and tumor necrosis factor-alpha (TNF-α).¹ Currently, there is no cure for psoriasis; nonetheless, there exists a variety of pharmacological strategies targeted at managing the clinical signs and symptoms.² In clinical practice, diagnosis is based on the use of techniques that support the assessment of severity, among which the determination of body surface area (BSA) stands out. Additional medical techniques widely used in practice are biopsy and Brocq's methodical scraping, which aids a more accurate diagnosis. Unfortunately, lack of access and untimely detection delay early treatment. It's estimated that 60 million people worldwide are affected by this health issue. The age range for psoriasis is between 30 and 60 years of age in men; whereas in women it can appear between 20 and 60 years of age.³

Commonly, the well-being of people with psoriasis is altered due to the evident skin lesions along with intense pruritus, insomnia, and the manifestation of mental health issues such as depression, anxiety, and suicide.⁴ MBI or meditation is a practice that emphasizes concentrating on the immediate awareness, free of judgment. MBI is considered a well-proven non-pharmacologic technique for stress management, and has shown advantages in a variety of clinical conditions, including chronic inflammatory diseases. MD has been widely studied for its positive effects on health. In particular, certain nutrients help reduce inflammation and oxidative stress, key processes in psoriasis, and contribute to body weight control, especially in cases of overweight or obesity.⁵ The objective of this review is to summarize the features of MBI in combination with a MD which could be applicable to the etiology of psoriasis, aiming specifically at inflammatory processes and lessening its clinical signs.⁶ This would seem to be suitable for putting these interventions into practice in outpatient settings, given that this context facilitates continuous education, empowers daily practice, and influences healthy habits, autonomy, prevention, and self-care, as it is known that in the hospital setting there are some limiting factors in terms of the food options and also the length of the hospital stay may be brief.

METHODS

A literature search was performed in PubMed using the terms “psoriasis,” “types of psoriasis,” “factors and psoriasis,” “pathophysiology and psoriasis or inflammation,” “mindfulness and psoriasis,” “psoriasis diagnosis,” “meditation and psoriasis,” and “cytokines and psoriasis.” The scope in terms of the publication scrutinized was between 2020 and 2025 due to the justification that the evidence from the last 5 years is more up-to-date, verifiable, and suitable for validating or amending previous insights. Studies in Spanish and English were included, with access to the full text as well as those which met peer review criteria. Randomized controlled clinical trials, cohort studies, meta-analyses, and review articles were selected. Manuscripts were selected by reviewing the titles, abstracts, or full texts. A total of 57 articles were assessed, underlining the importance of psoriasis, types, factors, diagnosis, and the use of mindfulness as a treatment in patients with psoriasis.

PSORIASIS

Psoriasis is a chronic inflammatory autoimmune disease marked by hyperproliferation and abnormal differentiation of keratinocytes (KC), the main cells of the epidermis.⁷ Usually, KCs divide by mitosis to form two new cells that mature and ascend to the upper layer and finally to the stratum corneum, where keratinization is finished. Following this, near 28 days after forming the basal layer, they expire and slough off. This is the lifespan of KCs in healthy skin. But in psoriatic skin, this process is incomplete, as it only lasts between 3 and 7 days, resulting in an excessive aggregation and development of hyperplastic skin, clinically manifested by thick plaques and abundant scales (Figure 1).⁸ In clinical practice, plaque psoriasis or vulgaris is the most common form, with an estimated prevalence of 3%; guttate psoriasis is present in 0.5% of the general population and 2% of the pediatric population.^9,10 Epidemiologically, pustular psoriasis affects 3% of the world's population; nail psoriasis is prevalent in 10% to 82% of the population with psoriasis, between 3% and 7% have flexural psoriasis, and erythrodermic psoriasis accounts for between 1% and 2% of patients with psoriasis (Table 1).^11-14 In general, in psoriatic plaques there is a synergistic interaction among the components of innate and adaptive immunity which occurs in a dysregulated form. In the context of classical immunology, antigen-presenting dendritic cells, KC, neutrophils, macrophages and NK cells are involved, which can modulate the immune response via specific receptors called killer cell immunoglobulin-like receptors (KIRs).

A particular type of the human leukocyte antigen (HLA), known as HLA-Cw6, plays a role as a natural ligand for the KIR2DL1 receptor, expressed on NK cells and some T lymphocytes. The atypical interaction between HLA-Cw6 and KIR2DL1 is capable of changing the function of these immune cells, promoting the chronic and dysregulated activation that is characteristic of the immunopathogenesis of psoriasis.¹⁹ The activation of dendritic cells in the dermis and epidermis, which is seen in the two phases of psoriasis, initial and aggravated, exhibits a set of inflammatory changes, highlighting the overproduction of cytokines such as TNF-α and IL-23, which promote the development of T cell subsets, Th1 and Th17, which later release proinflammatory mediators such as IL-17, IFN-γ and IL-22, which induce vascular and epidermal alterations.²⁰

PSORIASIS TRIGGERS

Factors triggering psoriasis comprise dietary factors such as consumption of saturated fats, simple carbohydrates, red meat, alcohol, overweight and obesity through increased leptin concentration in adipose tissue, which results in the activation of dendritic cells, granulocytes, macrophages and T cells by the ongoing pro-inflammatory process that occurs (Table 2).^21-23 Regardless of those factors which can activate psoriasis, a physiological condition which also increases cell proliferation, inflammation and impairs the function of KCs and fibroblasts is oxidative stress, either way by increased reactive oxygen species (ROS) or nitrogen (RNS) that induce transcription factors and other reactions linked to functions such as cell proliferation, autophagy and apoptosis.³⁹

At the upper left are located the triggering factors of this disease related to keratinocyte hyperproliferation. At the upper right part, all the varieties of psoriasis are listed. In the base layer of the image, the activation of dendritic cells in the dermis and inflammatory changes are described, highlighting the overproduction of cytokines such as TNf-α and IL-23, which promote the development of t-cell subsets, Th1 and Th17, which in turn secrete proinflammatory mediators such as Th-17, IFN-γ and IL-22, all of which promote vascular and epidermal alterations

CLINICAL DIAGNOSTIC TECHNIQUES

Psoriasis is classified according to the level of severity of skin involvement, for which different techniques are used in clinical practice to measure the area of the lesion. One of the most common is the determination of the BSA, which allows measuring the erythematous lesions, induration and desquamation of the same, generally the palm of the patient's hand is used as an indicator of the level of surface damage, since it represents 1% of the body extension.^3,40 In clinical practice, psoriasis is considered mild when the BSA value is 3%, moderate psoriasis when it affects between 3 to 8% and severe psoriasis when the value is more than 10%.⁴¹ Although this technique is easily accessible, some healthcare providers examine the patient and according to their judgment and previous medical impressions, make their diagnosis. This is a risky practice, because depending on the increase in BSA, the risk of developing new diseases, including cardiovascular, cerebrovascular and diabetes, may increase.⁴²

On the other hand, the psoriasis area and severity index (PASI) is another technique used in the second level of care due to its complexity and is commonly applied in dermatology. Briefly, this scale gives a score according to the severity of the skin lesions, four areas of the body are evaluated: head and neck, arms, trunk and legs. In each region, three key features of psoriasis are assessed: redness, plaque thickness and scaling, on a scale from 0 (absence) to 4 (maximum severity). Then, it is calculated how much of everybody area is affected, scoring according to the proportion involved. Finally, the severity score is multiplied by the area score to obtain a specific result by region, due to its complexity and the fact that experience is an important factor for the evaluation, this is only performed by dermatology specialists and finally its evaluation ranges from 0 (no presence of the disease) to 72 (severe case), being a valuable tool to measure how the patient responds to psoriasis treatment.^1,43

Another important technique is the methodical scraping of Brocq, which consists of curettage of a psoriatic plaque, managing to detect three signs: the sign of the stearin candle, where dry, white flakes that flake off the skin easily are obtained; the sign of the unfolding membrane, which is marked by the appearance of an epidermal film of brownish-white, wet texture with variable thickness, and the sign of the blood-soaked film or auspitz sign, where a bleeding spot appears in small drops at the base of the psoriatic plaque and erupts after the peeling of the membrane of Duncan-Dulckley, this is recognized as a pathognomonic sign. Irrespective of the chosen technique for diagnosis, a clinical history is taken, skin inspection is performed and a biopsy may be performed to confirm the presence of psoriasis.⁴⁴

Finally, a different significant tool for psoriasis patients that has an impact on their quality of life, not quite as much as diagnosis, is the dermatology life quality index (DLQI), a life quality assessment consisting of a 10-item questionnaire which includes questions concerning symptoms and feelings, daily activities, leisure, work, studies, personal relationships, and treatment. Each question is scored from 0 to 3, where 0 means no effect at all, 1 means a slight effect, 2 means a significant effect, and 3 means a very significant effect. A score of 0 is equal to no deterioration in quality of life, a score greater than 10 would indicate a moderate effect, and a score of 30 would indicate a severely reduced quality of life.⁴⁵

NON-PHARMACOLOGICAL TREATMENTS FOR PSORIASIS

Mindfulness

Also, known as MBI, meditation, or reflection, this non-invasive practice seeks to connect personal awareness with the environment from a neuroscientific approach, consciously observing the present moment, adopting an attitude of curiosity, openness, and acceptance, and abstaining from criticism or reaction to new experiences that emerge.⁴⁶ This practice consists of a variety of techniques designed to cultivate mental well-being, which are divided into two categories: physical activity focused on conscious movements, which integrates yoga, walking meditation, body scanning, and breathing; and internal attention based mainly on relaxation and body awareness, which also integrates sitting meditation, meditation exercises combined with cognitive behavioral techniques that identify negative thoughts to transform them into optimistic thoughts, group dialogues, and psychotherapy. Its effectiveness has been suggested in various pathologies such as anxiety, depression, improvement in harmful behaviors such as opioid and alcohol use, and behavior in attention deficit hyperactivity disorder, improving adherence to pharmacological treatment, as well as an important complement to therapies for people with cancer or cardiovascular diseases.⁴⁷

The human brain possesses the adaptive capacity to transform and reduce negative thoughts. Studies employed magnetic resonance imaging have shown changes in brain activity and structure, especially in the hypothalamus, by improving stress regulation, the prefrontal cortex related to decision-making and self-control, and the limbic system, including the amygdala and hippocampus, wherein it has been detected that the amygdala is less activated by negative stimuli.⁴⁸ Meditation has also been associated with reducing telomeres, showing positive effects in slowing age-related brain aging in young and middle-aged people. Clinical studies have also shown that it improves immune health by decreasing IL-6 concentration, promoting wellness such as autoimmune hepatitis, chronic low back pain due to symptomatic discopathy, psoriasis, inflammatory bowel disease, fibromyalgia, and rheumatoid arthritis.⁶

Use of mindfulness for psoriasis treatment

Mindfulness-based stress reduction (MBSR) has been demonstrated to be highly effective, focusing on sensations and behaviors to highlight personal autonomy, allowing individuals to organize, decide, and act without depending on others. Therapies based on the MBSR program have been shown to be effective in reducing stress, anxiety, and depression levels in older adults with psoriasis. Studies indicate that these practices improve adaptation strategies and quality of life, with sustained effects subsequent to treatment. A 10-week controlled trial evaluated the effects of three interventions: health education, psychotherapy, and MBSR in hypertensive patients with symptoms of depression and/or anxiety. The study included 30 participants (8 men and 22 women) and showed positive results: a reduction in depression and anxiety levels, a decrease in systolic blood pressure, and an improvement in patients' self-efficacy scores. A systematic review of the English-language literature on mind-body interventions as alternative and complementary therapies for psoriasis found that techniques such as visualization exercises, meditation, and cognitive-behavioral stress management produce mild to moderate clinical improvements. The study included 51 patients with psoriasis vulgaris, who were randomly assigned to a treatment group or a control group. Participants in the treatment group showed significant improvements in clinical indicators such as PASI, total sign score (TSS), and Doppler blood flow to psoriatic plaques.⁴⁹ A clinical trial studied the effects of a two-week intervention that combined psychological therapy, MBSR medical treatments, phototherapy, and progressive muscle relaxation in a group of 39 patients (14 men and 25 women). The results showed an increase in self-compassion, emotional resilience, and quality of life. In terms of skin condition, both groups experienced improvement during the interventions. In a randomized controlled clinical trial, 92 patients with psoriasis, aged 16 years and older, who were experiencing emotional distress were evaluated. Over a four-week period, participants underwent a compassion-based self-help intervention, which consisted of reading informational leaflets and listening to sound files with guided exercises. The results were positive, showing a significant reduction in extreme shame and self-criticism, as well as an increase in self-confidence and an improvement in the DLQI index.⁵⁰

A pilot study evaluated the effectiveness of an 8-week MBSR program focused on therapeutic breathing and synchronized yogic movement, combined with cognitive and behavioral methods focused on self-control and healthy decision-making. This intervention was combined with the use of immunosuppressive medication in 17 patients diagnosed with autoimmune hepatitis (AIH). The results showed a significant decrease in proinflammatory cytokine levels, including IL-6, IL-8, IL-10, IL-17, IL-23, as well as in the sCD74/MIF ratio. The latter, macrophage inhibitory factor (MIF), is a key mediator in both the psychological stress response and immune inflammation in AHI. Besides, an observation of increased stress levels, a reduction in the dose of immunosuppressive drugs, and a decrease in alanine aminotransferase (ALT) levels, an indicator of liver activity, were observed.⁴⁹ In a study of 70 patients with low back pain conducted in nine MBSR sessions, cortisol increase was attenuated, and a significant decrease in the proinflammatory cytokine IL-1β was found, as well as a reduction in depression, stress, perceived pain, an increase in quality of life in relation to sleep quality, an increase in physical function, and life satisfaction.⁵⁰ An experimental control study was performed to examine the effects of an MBI-based intervention in patients with end-stage renal disease. The study lasted 8 weeks and involved 62 participants, divided into two groups-31 in the experimental group and 31 in the control group. During hemodialysis sessions at the hospital, patients in the experimental group practiced the protocol developed by Smith in 2005 for 30 minutes, three times a week. The results showed a significant decrease in C-reactive protein (CRP) levels, a marker of inflammation, as well as a notable reduction in tumor necrosis factor alpha (TNF-α) levels, suggesting an anti-inflammatory effect associated with the practice. In a study conducted with patients diagnosed with Parkinson's disease, participants were assigned to two intervention groups. One group, consisting of 53 people, practiced meditation, while the other group, consisting of 52 patients, participated in yoga sessions. Both interventions were carried out for 8 weeks, with 90-minute sessions. At the end of the study, significant improvements were observed in both groups, including a reduction in anxiety symptoms, an improvement in health-related quality of life, and a decrease in serum levels of the proinflammatory cytokine IL-6. In a study called MBSR versus Escitalopram for the treatment of adults with anxiety disorders, the intervention was carried out over 8 weeks with daily 45-minute practices. Participants were divided into two groups: 102 received MBSR and 106 received escitalopram, with an average age of 33 years. The results were favorable; MBSR reduced anxiety as much as escitalopram, demonstrated a strong response, and was equally effective.

ANTI-INFLAMMATORY PROPERTIES OF MEDITEREANEAN DIET

As described above, environmental factors commonly influence the chronicity and success of treatment in psoriasis. Among these factors, diet and the consumption of certain nutrients play an important role in reducing inflammatory processes and oxidative stress. One of the most widely described diets is the MD, which not only has an impact on the disease but besides some comorbidities such as overweight or obesity that exacerbate the problem.⁵ For psoriasis, the nutritional contribution of certain foods is important, mainly antioxidants due to their anti-inflammatory properties that may have on the skin.⁵¹ Some studies on foods that may have an important effect are described below.

Salmon is a good source of omega-3 fatty acids: eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), and docosapentaenoic acid. Its wide range of benefits include anti-inflammatory, immunomodulatory, and antioxidant effects, as they inhibit the synthesis of the inflammatory leukotriene B, which in turn reduces inflammatory lesions.⁵¹ In a study conducted in cell culture and in vitro, showed key findings where EPA and DHA act as neuroprotective agents by counteracting the toxic effects of inflammatory cytokines associated with depression (IL-1β, IL -6, and IFN-α), preventing both the decrease in neurogenesis (marked by DCX+ and Map2+ cells) and the increase in apoptosis (CC3+ cells).⁵² Red wine consumption (2–7 servings per week) has been shown to have antioxidant effects due to its high polyphenol content. These compounds increase the activity of antioxidant enzymes such as catalase (CAT), superoxide dismutase (SOD2), and glutathione peroxidase (GPX1), facilitating the reduction of reactive oxygen species (ROS), suppressing NF-κB activation, diminishing proinflammatory cytokines such as IL-6 and TNF-α, and decreasing inflammatory biomarkers.⁵³ Oat-based cereals have been shown to decrease interleukin-10 (IL-10) and inhibit the expression of mRNA and proteins of proinflammatory factors such as TNF-α, IL-1β, IL-6, and iNOS. Nuts (hazelnuts, almonds, walnuts, pistachios, among others) contain gallic acid, a phenolic acid with antioxidant and anti-inflammatory properties. This compound regulates the inflammatory activity of T lymphocytes and macrophages/microglia, and reduces the release of interleukin-17 (IL-17) and interferon gamma (IFN-γ) by T lymphocytes. This compound has been shown to inhibit the production of several proinflammatory cytokines, including IL-4, IL-5, IL-17, IL-6, IL-1β, IL-12, IL-23, and TNF-α, by acting on cellular signaling pathways such as NF-κB. Grapes and cranberries contain resveratrol, a powerful antioxidant that has been shown to have anti-inflammatory properties that prevent the secretion of IL-2, MCP1, IL-8, and IFNγ. White beans and light red beans have been shown to reduce inflammatory markers such as IL-8 and TNF-α.

SYNERGY OF MINDFULNEES AND MEDITERRANEAN DIET IN COMPOUNDS OF PSORIASIS

MBI-based intervention combined with healthy eating and sustainable nutrition has shown itself to be an effective strategy for cognitive processes, cardiovascular conditions, eating disorders, overweight, etc. This type of practice supports individuals in reconnecting with their internal physiological conditions such as hunger and satiety, displacing the dependence on external stimuli that usually guide modern food consumption in excess. Likewise, MBI has been seen as positive in changing eating behaviors and, therefore, in people's health status. Also, its benefits in promoting healthy lifestyles and withdrawal from negative environmental factors such as smoking and alcoholism, which interfere with commitment to dietary treatment or healthy aspects in people, have been described.⁵⁴ On the other hand, the application of MBI with some types of diets, such as the MD, has been shown to have a positive impact on health factors. For example, in a randomized clinical trial of 1,184 pregnant women at risk of preterm birth, who received MBI (2.5 hours per week for 8 weeks) and a MD (provisions of extra virgin olive oil and nuts) showed that both interventions were effective in significantly reducing the proportion of small for gestational age (SGA) newborns (birth weight below the 10th percentile). In addition, a reduction in severe SGA (below the 3rd percentile) was observed. In the MBSR group, notable improvements were found in maternal anxiety and well-being levels, as well as a decrease in cortisol and some pro-inflammatory cytokines, which was reflected in improved placental function. There was also an average increase of 100 grams in birth weight, a clinically relevant change that has been associated with a 7% reduction in the risk of developing diabetes in adult life.⁵⁵

In another study performed over two years on pregnancy and child cognitive development, 1,221 pregnant women at risk of PEG participated and were divided into three groups: MD (olive oil and nuts), MBSR (eight 45-minute sessions), and usual care (no special intervention). At 24 months of age, the cognitive and socio-emotional development of the children was assessed using the Bayley-III scale, demonstrating that children in the MD group had positive changes in cognitive development and in the socio-emotional area, while the MBSR group only presented enhancements in socio-emotional development.⁵⁶ Finally, a 3-year study was conducted to learn about the MD and MBSR during pregnancy and their influence on the brain development of newborns. A total of 147 pregnant women were recruited and divided into three groups: MD with educational-focused sessions, free olive oil and nuts, MBRS group with an 8-week 45-minute program, and usual care without intervention. In addition, 692 infants (1-3 months old) were recruited to assess brain development. The interventions had significant changes in neonatal and fetal brain development.⁵⁷

This scientific evidence can help us better understand the relationship between MBI combined with other therapies such as dietary changes, which might be useful to study more in-depth, given the growing interest in mental health and forms of relaxation that are important in modern life and that trigger stress-related problems such as psoriasis. Future clinical studies are needed to understand the impact of MBI on modifiable habits such as diet.

CONCLUSION

The integration of MBI for 45 minutes daily, as recommended in modern literature, for more than 8 weeks as part of a comprehensive non-pharmacological approach, has been shown to be the period of time during which these MBI interventions have a significant impact on psoriasis in outpatients in combination with a MD are able to be provided as an effective complementary approach to reduce inflammation processes and shorten the recovery period for people with psoriasis, impacting the decrease in the PASI index, reduction of inflammatory cytokines such as TNF-α, IL-6, IL-8, IL-10, IL-17,1β IL-23, decrease in cortisol levels, and improvement in dermatological quality of life.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

REFERENCES

1. 1. Formisano E, Proietti E, Borgarelli C, Pisciotta L. Psoriasis and Vitamin D: A Systematic Review and Meta-Analysis. Nutrients. 2023;15(15).
2. 2. Sbidian E, Chaimani A, Guelimi R, Garcia-Doval I, Hua C, Hughes C, et al. Systemic pharmacological treatments for chronic plaque psoriasis: a network meta-analysis. Cochrane Database Syst Rev. 2023;7(7):CD011535.
3. 3. Raharja A, Mahil SK, Barker JN. Psoriasis: a brief overview. Clin Med (Lond). 2021;21(3):170-3.
4. 4. Nowowiejska J, Baran A, Grabowska P, Lewoc M, Kaminski TW, Flisiak I. Assessment of Life Quality, Stress and Physical Activity Among Patients with Psoriasis. Dermatol Ther (Heidelb). 2022;12(2):395-406.
5. 5. Aryanian Z, Asghari M, Zanousi PP, Ghadimi R, Kebria AS, Hatami P. Adherence to the Mediterranean diet in patients with psoriasis and its relationship with the severity of the disease: A case-control study. Health Sci Rep. 2024;7(9):e70049.
6. 6. Bartholomew E, Chung M, Yeroushalmi S, Hakimi M, Bhutani T, Liao W. Mindfulness and Meditation for Psoriasis: A Systematic Review. Dermatol Ther (Heidelb). 2022;12(10):2273-83.
7. 7. Zhou X, Chen Y, Cui L, Shi Y, Guo C. Advances in the pathogenesis of psoriasis: from keratinocyte perspective. Cell Death Dis. 2022;13(1):81.
8. 8. Rajguru JP, Maya D, Kumar D, Suri P, Bhardwaj S, Patel ND. Update on psoriasis: A review. J Family Med Prim Care. 2020;9(1):20-4.
9. 9. O'Toole A, Gooderham M. Topical Roflumilast for Plaque Psoriasis. Skin Therapy Lett. 2023;28(5):1-4.
10. 10. Leung AK, Barankin B, Lam JM, Leong KF. Childhood guttate psoriasis: an updated review. Drugs Context. 2023;12.
11. 11. Uppala R, Tsoi LC, Harms PW, Wang B, Billi AC, Maverakis E, et al. "Autoinflammatory psoriasis"-genetics and biology of pustular psoriasis. Cell Mol Immunol. 2021;18(2):307-17.
12. 12. Battista T, Scalvenzi M, Martora F, Potestio L, Megna M. Nail Psoriasis: An Updated Review of Currently Available Systemic Treatments. Clin Cosmet Investig Dermatol. 2023;16:1899-932.
13. 13. Guglielmetti A, Conlledo R, Bedoya J, Ianiszewski F, Correa J. Inverse psoriasis involving genital skin folds: successful therapy with dapsone. Dermatol Ther (Heidelb). 2012;2(1):15.
14. 14. Lo Y, Tsai TF. Updates on the Treatment of Erythrodermic Psoriasis. Psoriasis (Auckl). 2021;11:59-73.
15. 15. Galili E, Levy SR, Tzanani I, Segal O, Lyakhovitsky A, Barzilai A, et al. New-Onset Guttate Psoriasis: A Long-Term Follow-Up Study. Dermatol. 2023;239(2):188-94.
16. 16. Saleh D, Tanner LS. Guttate Psoriasis. StatPearls. Treasure Island (FL). 2025.
17. 17. Genovese G, Moltrasio C, Cassano N, Maronese CA, Vena GA, Marzano AV. Pustular Psoriasis: From Pathophysiology to Treatment. Biomedicines. 2021;9(12).
18. 18. Potestio L, Camela E, Cacciapuoti S, Fornaro L, Ruggiero A, Martora F, et al. Biologics for the Management of Erythrodermic Psoriasis: An Updated Review. Clin Cosmet Investig Dermatol. 2023;16:2045-59.
19. 19. Vicic M, Kastelan M, Brajac I, Sotosek V, Massari LP. Current Concepts of Psoriasis Immunopathogenesis. Int J Mol Sci. 2021;22:21.
20. 20. Sieminska I, Pieniawska M, Grzywa TM. The Immunology of Psoriasis-Current Concepts in Pathogenesis. Clin Rev Allergy Immunol. 2024;66(2):164-91.
21. 21. Griffiths CEM, Armstrong AW, Gudjonsson JE, Barker J. Psoriasis. Lancet. 2021;397(10281):1301-15.
22. 22. Kanda N, Hoashi T, Saeki H. Nutrition and Psoriasis. Int J Mol Sci. 2020;21:15.
23. 23. Hwang J, Yoo JA, Yoon H, Han T, Yoon J, An S, et al. The Role of Leptin in the Association between Obesity and Psoriasis. Biomol Ther (Seoul). 2021;29(1):11-21.
24. 24. Rajasekharan A, Munisamy M, Menon V, Mohan Raj PS, Priyadarshini G, Rajappa M. Stress and psoriasis: Exploring the link through the prism of hypothalamo-pituitary-adrenal axis and inflammation. J Psychosom Res. 2023;170:111350.
25. 25. Petit RG, Cano A, Ortiz A, Espina M, Prat J, Munoz M, et al. Psoriasis: From Pathogenesis to Pharmacological and Nano-Technological-Based Therapeutics. Int J Mol Sci. 2021;22:9.
26. 26. Anand S, Littler DR, Mobbs JI, Braun A, Baker DG, Tennant L, et al. Complimentary electrostatics dominate T-cell receptor binding to a psoriasis-associated peptide antigen presented by human leukocyte antigen C *06:02. J Biol Chem. 2023;299(7):104930.
27. 27. Singh S, Pradhan D, Puri P, Sharma S, Jain AK. Profiling CARD14 gene expression in Indian Psoriasis patients. Sci Rep. 2024;14(1):28798.
28. 28. Liu S, He M, Jiang J, Duan X, Chai B, Zhang J, et al. Triggers for the onset and recurrence of psoriasis: a review and update. Cell Commun Signal. 2024;22(1):108.
29. 29. Duchnik E, Kruk J, Tuchowska A, Marchlewicz M. The Impact of Diet and Physical Activity on Psoriasis: A Narrative Review of the Current Evidence. Nutrients. 2023;15:4.
30. 30. Medovic MV, Jakovljevic VL, Zivkovic VI, Jeremic NS, Jeremic JN, Bolevich SB, et al. Psoriasis between Autoimmunity and Oxidative Stress: Changes Induced by Different Therapeutic Approaches. Oxid Med Cell Longev. 2022;2022:2249834.
31. 31. Laguardia F, Owczarczyk-Saczonek A, Maggi P. The role of smoking in psoriasis. Postepy Dermatol Alergol. 2024;41(2):143-8.
32. 32. Potestio L, Lauletta G, Tommasino N, Portarapillo A, Salsano A, Battista T, et al. Risk Factors for Psoriasis Flares: A Narrative Review. Psoriasis (Auckl). 2024;14:39-50.
33. 33. Zhou S, Yao Z. Roles of Infection in Psoriasis. Int J Mol Sci. 2022;23(13).
34. 34. Yeroushalmi S, Hakimi M, Chung M, Bartholomew E, Bhutani T, Liao W. Psoriasis and Exercise: A Review. Psoriasis (Auckl). 2022;12:189-97.
35. 35. Roszkiewicz M, Dopytalska K, Szymanska E, Jakimiuk A, Walecka I. Environmental risk factors and epigenetic alternations in psoriasis. Ann Agric Environ Med. 2020;27(3):335-42.
36. 36. Marek-Jozefowicz L, Czajkowski R, Borkowska A, Nedoszytko B, Zmijewski MA, Cubala WJ, et al. The Brain-Skin Axis in Psoriasis-Psychological, Psychiatric, Hormonal, and Dermatological Aspects. Int J Mol Sci. 2022;23:2.
37. 37. Gisondi P, Geat D, Bellinato F, Spiazzi L, Danese E, Montagnana M, et al. Psychological Stress and Salivary Cortisol Levels in Patients with Plaque Psoriasis. J Pers Med. 2021;11:11.
38. 38. Alesci A, Lauriano ER, Fumia A, Irrera N, Mastrantonio E, Vaccaro M, et al. Relationship between Immune Cells, Depression, Stress, and Psoriasis: Could the Use of Natural Products Be Helpful? Molecules. 2022;27:6.
39. 39. Plenkowska J, Gabig-Ciminska M, Mozolewski P. Oxidative Stress as an Important Contributor to the Pathogenesis of Psoriasis. Int J Mol Sci. 2020;21:17.
40. 40. Reolid A, Servitje O, Ginarte M, Perez-Ferriols A, Velez A, Aragues M, et al. Validation of an Optical Pencil Method to Estimate the Affected Body Surface Area in Psoriasis. Actas Dermosifiliogr (Engl Ed). 2020;111(2):143-8.
41. 41. Ogdie A, Shin DB, Love TJ, Gelfand JM. Body surface area affected by psoriasis and the risk for psoriatic arthritis: a prospective population-based cohort study. Rheumatology (Oxford). 2022;61(5):1877-84.
42. 42. Lin YL, Huang A, Yang CY, Chang WY. Measurement of Body Surface Area for Psoriasis Using U-net Models. Comput Math Methods Med. 2022;2022:7960151.
43. 43. Papp KA, Lebwohl MG, Kircik LH, Pariser DM, Strober B, Krueger GG, et al. The Proposed PASI-HD Provides More Precise Assessment of Plaque Psoriasis Severity in Anatomical Regions with a Low Area Score. Dermatol Ther (Heidelb). 2021;11(4):1079-83.
44. 44. Miceli A, Schmieder GJ. Palmoplantar Psoriasis. StatPearls. Treasure Island (FL). 2025.
45. 45. Rencz F, Gulacsi L, Pentek M, Szegedi A, Remenyik E, Bata-Csorgo Z, et al. DLQI-R scoring improves the discriminatory power of the Dermatology Life Quality Index in patients with psoriasis, pemphigus and morphea. Br J Dermatol. 2020;182(5):1167-75.
46. 46. Schuman-Olivier Z, Trombka M, Lovas DA, Brewer JA, Vago DR, Gawande R, et al. Mindfulness and Behavior Change. Harv Rev Psychiatry. 2020;28(6):371-94.
47. 47. de Aguiar KR, Bilhalva JB, Cabelleira MD, Guimaraes GO, Madureira T, Agako A, et al. The impact of mindfulness on suicidal behavior: a systematic review. Trends Psychiatry Psychother. 2022;44:e20210316.
48. 48. Gotink RA, Meijboom R, Vernooij MW, Smits M, Hunink MG. 8-week Mindfulness Based Stress Reduction induces brain changes similar to traditional long-term meditation practice - A systematic review. Brain Cogn. 2016;108:32-41.
49. 49. Alrabadi LS, Dutton A, Rabiee A, Roberts SJ, Deng Y, Cusack L, et al. Mindfulness-based stress reduction may decrease stress, disease activity, and inflammatory cytokine levels in patients with autoimmune hepatitis. JHEP Rep. 2022;4(5):100450.
50. 50. Diez GG, Anitua E, Castellanos N, Vazquez C, Galindo-Villardon P, Alkhraisat MH. The effect of mindfulness on the inflammatory, psychological and biomechanical domains of adult patients with low back pain: A randomized controlled clinical trial. PLoS One. 2022;17(11):e0276734.
51. 51. Garbicz J, Calyniuk B, Gorski M, Buczkowska M, Piecuch M, Kulik A, et al. Nutritional Therapy in Persons Suffering from Psoriasis. Nutrients. 2021;14(1).
52. 52. Borsini A, Nicolaou A, Camacho-Munoz D, Kendall AC, Di Benedetto MG, Giacobbe J, et al. Omega-3 polyunsaturated fatty acids protect against inflammation through production of LOX and CYP450 lipid mediators: relevance for major depression and for human hippocampal neurogenesis. Mol Psychiatry. 2021;26(11):6773-88.
53. 53. Lombardo M, Feraco A, Camajani E, Caprio M, Armani A. Health Effects of Red Wine Consumption: A Narrative Review of an Issue That Still Deserves Debate. Nutrients. 2023;15:8.
54. 54. Lieffers JRL, Quintanilha M, Trottier CF, Johnson ST, Mota JF, Prado CM. Experiences with and Perception of a Web-Based Mindfulness, Nutrition, and Fitness Platform Reported by First-Year University Students: A Qualitative Study. J Acad Nutr Diet. 2021;121(12):2409-18e3.
55. 55. Crovetto F, Crispi F, Casas R, Martin-Asuero A, Borras R, Vieta E, et al. Effects of Mediterranean Diet or Mindfulness-Based Stress Reduction on Prevention of Small-for-Gestational Age Birth Weights in Newborns Born to At-Risk Pregnant Individuals: The IMPACT BCN Randomized Clinical Trial. JAMA. 2021;326(21):2150-60.
56. 56. Crovetto F, Nakaki A, Arranz A, Borras R, Vellve K, Paules C, et al. Effect of a Mediterranean Diet or Mindfulness-Based Stress Reduction During Pregnancy on Child Neurodevelopment: A Prespecified Analysis of the IMPACT BCN Randomized Clinical Trial. JAMA Netw Open. 2023;6(8):e2330255.
57. 57. Nakaki A, Crovetto F, Urru A, Piella G, Borras R, Comte V, et al. Effects of Mediterranean diet or mindfulness-based stress reduction on fetal and neonatal brain development: a secondary analysis of a randomized clinical trial. Am J Obstet Gynecol MFM. 2023;5(12):101188.