STRENGTHS AND LIMITATIONS OF THIS STUDY

This review included studies conducted in different settings, which emphasised the non-pharmacological interventions for patients with psoriasis.

It is the first scoping review on a nationwide healthcare model of patients with psoriasis.

A scoping review method was chosen to include different study designs. Therefore, it does not involve a detailed critical appraisal of individual studies or meta-analyses.

Considering the partial databases selected and the non-inclusion of grey literature, the results are used only as an overview of the field.

The study was not designed to assess methodological quality.

Introduction

Psoriasis is a common chronic, relapsing, immune-mediated systemic inflammatory skin condition affecting >125 million people globally.1 2 Approximately 30% of patients with psoriasis may develop psoriatic arthritis, and the comorbid risk of developing cardiovascular, chronic kidney and inflammatory bowel diseases, malignant tumour, infection, metabolic syndrome and a mental disorder is significantly increased.3 4 The incidence of psoriasis has increased with the deteriorating environment and various pressures.5 6 Patients suffer from skin damage and physical and mental disorders due to damaged skin integrity, embarrassment, inferiority complex, anxiety and depression, affecting their psychology, social life and work.7 Psoriasis has undoubtedly become a serious public health concern due to the impairment of quality of life (QOL).8 9

Recently, many scholars have explored the healthcare model (HCM) for patients with psoriasis. A PsPSP model of high-quality, holistic, patient-focused healthcare lifestyle and living with psoriasis and a PsoWell clinic were established.10 11 To promote the conversion of psoriasis evidence, ProvenCare management model was proposed, which aimed at the obstacles in the implementation of evidence, such as a lack of standardised disease severity scores, standardised treatment methods and uniform fees for non-pharmacological interventions in electronic health records.12 A national plan led by the German Psoriasis Network (PsoNet) was initiated to improve the quality of care in patients with psoriasis.13 An IMPROVE model was established in Denmark for patients with psoriasis and articular psoriasis to ensure they get the best care and eliminate inappropriate incentives in the current compensation system.9 Notably, many non-pharmacological interventions, such as multidisciplinary teams,6 14 15 educational interventions (therapeutic patient education, psychoeducational intervention and self-management education),2 6 14–40 psychosocial interventions (cognitive and behavioural treatments, self-help and peer-to-peer (P2P) support programme)6 15 18 22 24 41–55 and others (happify and motivational interviewing-based training) have proven to be effective.44 56

However, no systematic review of non-pharmacological interventions for patients with psoriasis has been performed. This scoping review aimed to identify various non-pharmacological interventions for patients with psoriasis by mapping existing literature in the field. It also provided a basis for constructing a protocol for HCM and summarising non-pharmacological interventions to assist patients with psoriasis in adjusting to changes.

Methods

A scoping review can examine and clarify broader areas than that of a systematic review; therefore, it was chosen to allow for the inclusion of different study designs. Following the methodology model proposed by Arksey and O’Malley, various pieces of evidence were mapped.57 This review follows the PRISMA-ScR guidelines58 included in online supplemental material 1. The other steps used are organised as follows.

Stage 1: identifying the research questions

This scoping review aimed to identify various non-pharmacological interventions for patients with psoriasis by mapping existing literature in the field. It provides a basis for constructing a protocol for HCM and a foundation for summarising non-pharmacological interventions to help patients with psoriasis adjust to changes.

Stage 2: identifying relevant studies

The search strategy involved consulting information specialists, the preretrieval of databases and project team discussions (online supplemental material 2). EMBASE, PubMed, CINAHL, PsycINFO and Scopus databases were chosen and retrieved from their inception to June 2022 for publications with no language limitations. They covered a wide range of subjects, including medicine, psychosociology and nursing. EndNote was applied to exclude duplicate records and incorporate the included literature.

Stage 3: selecting the literature

The inclusion criteria were as follows.

Population

Patients diagnosed with psoriasis by dermatologists.

Range of concepts

Non-pharmacological interventions for patients with psoriasis.

Context

Adults aged ≥18 years.

Notably, all articles provided primary data on non-pharmacological interventions for patients with psoriasis from its inception to 2022. First, to avoid missing valuable literature, two researchers conducted three rounds of assessment that included reading study titles and abstracts to meet the inclusion and exclusion criteria. Subsequently, the full texts of the studies identified through screening were independently evaluated for eligibility by two authors. Third, the studies were classified for mapping based on the definitions and descriptions of the methods provided in the publication.59 Finally, data extraction was performed by an author (a Joanna Briggs systematic review researcher) using a structured form. Another author verified the accuracy of the data extracted from the included studies. Disagreements were resolved through a larger team discussion.

Stage 4: charting the data

A total of 71 articles were included in this review and subjected to data charting. The data charting considered the following: author(s), publication year, country of origin, study type, sample population, sample size, intervention name, intervention content, intervention frequency, project implementers, follow-up and outcomes of non-pharmacological interventions for patients with psoriasis.

Stage 5: collating, summarising and reporting the literature

Non-pharmacological interventions for patients with psoriasis include two levels: organisational and individual. Organisational non-pharmacological interventions include a nationwide healthcare programme, innovative teledermatology models and multidisciplinary intervention. Individual non-pharmacological interventions include educational and psychosocial interventions.

Patient and public involvement

Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Results

The search strategy yielded 1322 papers. After excluding duplicates (n=422) and eliminating 829 by a first pass through the titles and abstracts, potentially relevant literature was screened in two rounds, resulting in 71 studies (figure 1). The characteristics of the included studies are summarised in table 1. The non-pharmacological interventions for patients with psoriasis from the organisational and individual interventions are shown in online supplemental material 3 (figure 2). Organisational non-pharmacological interventions include nationwide HCM, innovative teledermatology models and multidisciplinary interventions. Individual non-pharmacological interventions include educational and psychosocial interventions.

Figure 1

Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram illustrating literature search and selection.

Table 1

Mapping of study characteristics of all studies included in this review

Figure 2

Non-pharmacological interventions for patients with psoriasis.

Different nationwide HCMs of patients with psoriasis

Recently, many researchers have explored HCM in patients with psoriasis. The PsPSP model of high-quality, holistic, patient-focused healthcare lifestyle and living with psoriasis was established10; personal models in clinical management60 and a PsoWell clinic were also established.11 ProvenCare management model in the USA was proposed to promote the conversion of psoriasis evidence. It aims to address obstacles in implementing evidence, such as the lack of standardised disease severity scores, standardised treatment methods and uniform fees for non-pharmacological interventions in electronic health records.12 A national plan was initiated to improve the quality of care for patients with psoriasis led by the German PsoNet and PsoHealth.13 61 62 The patient burdens, economic impacts and care barriers were systematically analysed from a comprehensive care structure and process analysis. Guidelines, evaluation systems and treatment goals were also developed to optimise routine care. The annual psoriasis healthcare conference aimed to establish care goals, and a monitoring system confirmed that the goal-oriented national psoriasis coordination plan could improve the quality of care, reduce the disease severity and improve patients’ QOL. Therefore, an IMPROVE model was established in Denmark for patients with psoriasis and psoriatic arthritis to ensure that they receive the best care and eliminate inappropriate incentives in the current compensation system.9 Natural follow-up was used to collect the main treatment models and disease burden of patients; medical and health departments currently use conceptual maps to determine patients' concerns about the disease, conduct interviews with relevant stakeholders to assess quantitative indicators of patients' concerns about outcomes and establish salary models for medical and health-related personnel. Canada recently launched the psoriasis educational website.39

Innovative teledermatology models of patients with psoriasis

The development of teledermatology provides a broader space for healthcare in patients with psoriasis. Innovative teledermatology models can encourage collaborative care, and patient engagement is equivalent to inperson care for improving functional status and psychological health in patients with psoriasis.63–65 A mobile phone-based disease monitoring application for patients with psoriasis in combination with a patient educational programme was developed and applied.17 Allay mHealth intervention, a 12-week bespoke digital therapeutic intervention for patients with psoriasis, is designed as an adjunct to medical management of the condition, which may help patients improve resilience, mood and beliefs on their condition and enhance their QOL.66 Using a participatory design, the mHealth app supported the self-management of patients with psoriasis.65 67 The Electronic Targeted Intervention (eTIPs study) for patients with psoriasis was established.68 The American Academy of Dermatology and National Psoriasis Foundation websites provided publicly available patient educational materials addressing psoriasis.28 Consequently, an internet-based cognitive behavioural therapy was proposed, consisting of five flexible treatment modules containing various cognitive and behavioural techniques focused on themes that patients with psoriasis often experience, such as itch, pain, fatigue, negative mood and social relationships.43 49

Multidisciplinary interventions for patients with psoriasis

The healthcare of patients with psoriasis requires a multidisciplinary team that includes dermatologists, pharmacists, nurses specialised in skin care, psychologists, physicians, sports teachers, dieticians and philosophers, among others.6 15 34 56 67 The development and implementation of a nurse-led home phototherapy programme designed to prevent clinical inertia and support patients' success in learning self-management for their chronic skin conditions at home and an outline study protocol designed to evaluate the health outcomes and clinical resource utilisation from the home phototherapy programme are necessary.69

Educational interventions for patients with psoriasis

Educational programmes might positively affect the long-term management of psoriasis.26 27 29 30 32 70 However, patients who chose to participate in an educational programme showed an increase in knowledge and self-expertise in psoriatic disease.20 21 23 HautTief multidisciplinary educational programmes may improve the QOL and reduce depression in patients with psoriasis or atopic dermatitis.15 Based on message framing, the educational interventions of patients with psoriasis seem more critical for both health literacy and increased patients’ knowledge.6 16 71 Patients with psoriasis may need multiple approaches and repetitions over time to become and remain literate and become effective self-managers.16 Therapeutic patient education and self-management support were provided.23 28 Self-management education included three sessions of group classes for 20–30 min, discussions, educational booklets and telephone follow-up.26 The educational interventions for patients with psoriasis include lectures on skin disease conditions (clinical presentation, epidemiology, aetiology and disease burden), lifestyle factors (nutrition, sleep hygiene, smoking cessation, substance abuse, practical philosophy, religion and spirituality) and psychoeducation (psychodermatology and coping strategies), among others.33 35–38 41 72

Psychosocial interventions for patients with psoriasis

Effective dermatological treatments are available for psoriasis; however, some individuals experience psychological distress that is not managed by these treatments. Psychological intervention may improve QOL and the therapeutic efficacy of drugs in patients with psoriasis.19 21 22 73–77 Cognitive behavioural therapies (CBT) as an adjunct to conventional treatments may be particularly rewarding for patients with more severe pretreatment psychopathology in improving psoriasis severity, anxiety and depression symptoms.6 18 40 42 51 52 55 CBT includes psychoeducation, cognitive interventions, behavioural techniques, relaxation, imagery training, meditation, biofeedback and homework assignments.15 22 27 31 46 47 50 54 After an 8-week systematic psychotherapeutic intervention, three superordinate themes emerged: enhanced approach-oriented coping skills, reduced negative thinking and improved mental and physical health.46 An additional 8-week intervention with CBT combined with biofeedback increases the beneficial effect of ultraviolet B(UVB) therapy in the overall management of psoriasis, reduces the clinical severity of psoriasis, improves the level of QOL and lowers the number of minor psychiatric disorders.50 Self-help has been found to treat emotional disorders in patients with psoriasis effectively.44 78 79 Self-help based on compassion and mindfulness is acceptable to users. It can reduce feelings of shame and improve the QOL in patients with psoriasis.25 43 The motivational interview was applied in PsoWell clinic11 and clinical practice.22 34 P2P supporting programme allowed patients with psoriasis to share their experiences one on one.53 The ‘Happify’, a publicly available digital well-being programme accessible on the website or mobile phone app, comprises games and activities based on positive psychology, CBT and mindful principles.45 Additional psychological support, needs and well-being in psoriasis were assessed and improved.54

Discussion

This scoping review analysed the contents of 71 papers with twofold results: (1) organisational non-pharmacological interventions included nationwide HCM, innovative teledermatology models and multidisciplinary intervention, and (2) individual non-pharmacological interventions included educational intervention and psychosocial intervention, which provided a basis for formulating a protocol of HCM and non-pharmacological interventions for patients with psoriasis.

As a refractory chronic skin disease, psoriasis has been the focus of researchers to meet long-term healthcare needs and reduce the disease burden.80 81 However, the subjective and objective care needs and supply of psoriasis are not ideal. With the rapid growth of psoriasis treatment and healthcare-related research, a large information network has been established.2 82–84 It takes approximately 10–20 years for the original evidence to be applied in practice, resulting in a gap between evidence and practice.85 Therefore, effective interventions cannot be applied to healthcare. In contrast, some ineffective or harmful interventions are still used, resulting in low efficiency of knowledge transfer, poor care effects, waste of health resources and inequality,86 which may also be associated with the complexity of long-term healthcare for patients with psoriasis.87 According to the Consolidated Framework for Implementation Research, the rudiment of the care model was constructed. With the patient’s (P) healthcare needs as the core, the PSORIASIS HCM was defined using a care schema (S), organisation form (OR), intervention (I), assessment index (A) and standardisation process (S) (figure 3).

Figure 3

A protocol of healthcare model in people with psoriasis.

Individual non-pharmacological interventions included educational interventions (therapeutic patient education, psychoeducational intervention and self-management education), psychosocial interventions (CBT, self-help and P2P support programmes) and others (happify and motivational interviewing-based training). Educational interventions for patients with psoriasis are becoming increasingly critical to improve health-related QOL, disease severity and treatment adherence. This review included studies conducted in different settings, which emphasised the non-pharmacological interventions for patients with psoriasis. A scoping review method was used to allow the inclusion of varying study designs, and it did not involve a detailed critical appraisal of individual studies or meta-analyses. Considering the partial databases selected and the grey literature not included, the results were used only as an overview of the field.

Conclusion

Research on psoriasis HCM includes the current healthcare situation from the management perspective; however, those from the physiological, psychological and social perspectives with patients' healthcare needs as the core of the relevant research are scarce. This review describes HCM and non-pharmacological interventions for patients with psoriasis, which could contribute to developing new HCM. The HCM protocol, based on previous theory and research, could provide directions for care and policies that promote the QOL of patients with psoriasis. Further research is necessary to examine the effectiveness of non-pharmacological interventions based on the protocol of the HCM for patients with psoriasis.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

Ethics statementsPatient consent for publication

Not applicable.

Ethics approval

Not applicable.