Biofeedback and Self-Regulation, I,'ol. 19, No. 4, 1994

An Hypothesis Explaining the Successful Treatment of Psoriasis with Thermal Biofeedback: A Case Report

M a r k Goodman 1,2

The Union Memorial Hospital, Baltimore

This is a single case report of a 56-year-old Caucasian female referred for biofeedback by her dermatologist after seven years of failed standard medical treatment for psoriasis. Patient's presenting complaint was the embarrassing psoriasis lesions on her arms. Following 13 weekly one-hour finger/hand thermal biofeedback treatments, all 11 presenting psoriasis lesions (2-6 cm) had disappeared. Interestingly, any new psoriasis lesions that surfaced during our treatment disappeared without leaving palpable or visible scarring~ unlike lesions that were present prior to biofeedback treatment. Patient was unmedicated for psoriasis during our treatment and continues to be unmedicated and asymptomatic at 12-month follow-up.

Descriptor Key Words: psoriasis; thermal biofeedback.

Psoriasis is a noncontagious chronic disease marked by epidermal prolif- eration of the skin. Its lesions usually appear initially as small erythematous papules and enlarge or coalesce to form red elevated plaques with silvery scales at various anatomic sites (Diseases and Disorders Handbook, 1990). Psoriasis is characterized by recurring remissions and exacerbations orten

1This study was done while the author was affiliated with the Homewood Hospital/The Johns Hopkins Health Care System, Baltimore, Maryland.

2Address all correspondence to Dr. Goodman, c/o Terri Harold, Secretary, The University of Maryland Baltimore County, Department of Psychology & Behavioral Medicine, 5401 Wilkens Avenue, Baltimore, Maryland 21228. The author expresses gratitude to Dr. Russell Hibler for his invaluable biofeedback supervision on this case, and to Terri Harold for manuscript preparation and editing.

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348 Goodman

related to unpredictable systemic/environmental factors such as pregnancy, cold weather, and emotional stress.

The etiology and pathogenesis of psoriasis remain an enigma. Fine (1988) states that psoriasis is an autoimmune disorder, as do Reeves and associates (1986), who go on to "cite clinical evidence that there is an in- timate relationship between psoriasis and autoimmunity and that this as- sociation may comprise an unusual if not unique type of collagen vascular disease . . ." (p. 18), similar in many ways to Raynaud's syndrome or poly- myositis scleroderma.

Skin, the largest organ of the body, responds to emotional stimuli (e.g., facial blushing due to embarrassment, which is a modification of blood circulation beneath the skin). Health of the skin is dependent upon proper subcutaneous blood flow. Modification of blood circulation beneath the skin from vasoconstricting stressors which shunt blood away from the periphery or upper layers of the skin may result in cutaneous ischemia, urticaria (hives; Shelley & Shelley, 1985), telogen effluvian (Kligman, 1961), pruritis (itching), and psoriasis (Jellner, Arnetz, Enerother, & Kaliner, 1985; Koblenzer, 1988; Rook & Dawber, 1982).

Thus, the skin is an excellent dependent measure for studying psy- chophysiology/behavioral medicine because of its easily observed, noninva- sive "hard endpoints." Hence this report is quite relevant because of the paucity of successful treatment data currently in the literature on psoriasis and psychophysiology.

M E T H O D

The patient was a 56-year-old widowed Caucasian female (Ms. S.), referred for biofeedback to our service by her dermatologist as a "last ef- fort" at successfully treating her 10-year history of unremitting psoriasis. The patient was primarily interested in the amelioration of psoriasis lesions on her arms that would allow for reduced embarrassment when wearing short-sleeved clothing. The patient reported physical abuse from her hus- band for 25 years, which ended when her husband died and coincided with the onset of psoriasis. This association was one of several topics reportedly discussed in counseling following the death of the patient's husband. Her presentation did not fit PTSD criteria, but was viewed as the result of a chronic sympathetic hyperarousal syndrome. Her medical history was non- contributory except for osteo-arthritis, which responded weil to treatment with 800 mg of ibuprofen daily.

Biofeedback for Psoriasis 349

Apparatus

A Bio-Lab biofeedback system with computer graphics and two-chan- nel thermal capability was used.

Procedures

A history was taken at session 1. At session 2, instructions on warming of the peripheral site as a method of increasing cutaneous and subcutane- ous blood circulation were taught to and practiced by the patient (as in subsequent sessions), through the use of diaphragmatic breathing and cue- ing. Homework practice (diaphragmatic breathing/biofeedback) by the pa- tient was performed twice daily with compliance checks. Frequent rotation of thermal observation sites was performed to increase response generali- zation. The thermal observation placement site(s) for each session was a function of observable skin results. All subsequent biofeedback sessions lasted one hour. The initial seven minutes of each session consisted of base- line basal peripheral temperature recording at the hand site chosen for the session. Initiation of each session was preceded by a 15-20-minute psycho- physiological stabilization period in a climaticaUy controlled room (68-70°F) in which the patient was seated, typically relaxing by reading.

Single-channel thermal biofeedback began at session 3. For sessions 3 and 4, the surface thermistor was attached with paper tape only to the index fingertip pad of the dominant right hand. In session 5 attachment of the surface thermistor was made to the small finger of the right hand only, and in session ö to the web space between the index finger and thumb only of the right hand. Sessions 7-9 used similar sites on the left hand only. Sessions 10 and 11 used two-channel thermal biofeedback with a bilateral web placement. Sessions 12 and 13 again used bilateral web placement, with the patient standing and exposed to random and intermittent cold breezes, conversation, and aversive distraction, such as a loud radio.

RESULTS

Hand warming via visuaUy assisted thermal biofeedback was chosen since it is a well-documented procedure used to increase upper extremity peripheral blood circulation, and has been shown to be of some benefit in Raynaud's disease.

Baseline temperature for the right hand index finger while seated was 84.4°F prior to initial training. By session 6 the patient was able to maintain

350 Goodman

a right hand temperature of 91.2°F (_+2°F), and the psoriasis patches had decreased from five on the right arm to two patches, neither larger than 3.5 cm. Left-hand thermal biofeedback commenced at session 7 since no decrease in psoriasis lesions was evident on the left arm, and it was believed that the response was too regional specific and would not otherwise gen- eralize.

Baseline temperature for the left hand index finger while seated was 83.7°F prior to initial training on the left hand. By session 9 the patient was able to maintain a left-hand temperature of 90.1°F (_+l.2°F), and the psoriasis patches on the left arm decreased from six to four, none larger than 4 cm.

Bilateral biofeedback commenced in sessions 10-13 and the psoriasis patches continued to disappear. (See Figure 1 for mean temperature values for each baseline period and each session.) Between sessions 5 and 8 three new patches surfaced and quickly disappeared within several weeks of bio- feedback thermal warming training. Interestingly, these three patches left no palpable scarring or discoloration as compared to preexisting patches.

DISCUSSION

The results of this case report would support Reeves et al.'s (1986) assertions that an intimate relationship may exist between psoriasis, autoim- munity, and a unique type of collagen vascular disease, since thermal

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Biofeedback for Psoriasis 351

(warming) biofeedback training was successful in treating and maintaining remission at 12-month follow-up in this case.

Clearly, the literature is replete with articles on skin reactions asso- ciated with psychosocial stress and resultant pathophysiology from immu- nocompromise (see reviews by Koblenzer, 1988; Koo & Pham, 1992; Whitlock, 1976). Admittedly, the mechanism of action of thermal biofeed- back in this successful treatment of psoriasis is unknown, although Sedlacek (1989) also cites cases in which psoriasis has cleared with thermal biofeed- back. It is, however, weil documented by McGrady et al. (1992) that bio- feedback-assis ted relaxation in healthy adults can effect increased blastogenesis and decrease white blood cell count (within normal limits) due to decreased neutrophils. Thus, biofeedback may be viewed as having psychoneuroimmunologic value in restoring and/or maintaining homeosta- sis, and a calmer, less label central nervous system and brain also may help the skin heal (Sedlacek, 1989). Similarly, other psychophysiologic proce- dures which may exert a calming effect, such as hypnosis, have also been reported to produce effective site-specific results for ichthyosiform erythroderma, another skin disorder (Kidd, 1966; Mason, 1955; Schneck, 1966).

It is hypothesized that this treatment was, and continues to be, suc- cessful because of the reinforcing consequences of a gradual reduction in psoriasis patches to zero, mediated through increased regional blood cir- culation to affected areas via a diaphragmatic vagal/parasympathetic nerv- ous system response.

REFERENCES

Diseases and disorders handbook (1990). Springhouse, PA: Springhouse Corporation, pp. 625-627.

Fine, R. M. (1988). The Fine page: Psoriasis and autoimmune disease. International Journal of Dermatology, 27(1), pp. 17-18.

Jellner, B., Arnetz, B. B., Enerother, P., & Kallner, A. (1985). Pruritis during standardized mental stress: Relationship to psychoneuroendocrine and metabotic parameters. Acta Dermatologic Venereologic, 65, 199-205.

Kidd, C. B. (1966). Congenital ichthyosiform erythroderma treated by hypnosis. British Journal of Dermatology, 78, 101-105.

Kligman, A. M. (1961). Pathologic dynamics of human hair loss: Telogen effluvian. Archives of Dermatology, 83, 175-198.

Koblenzer, C. S. (1988). Stress and the skin. Advances, 5, 27-32. Koo, J. Y., & Pham, T. (1992). Psychodermatology. Archives of Dermatology, 128, 381-388. Mason, A. A. (1955). Ichthyosis and hypnosis. British Medical Journal, 2, 57. McGrady, A., Conran, P., Dickey, D., Garman, D., Farris, E., & Schumann-Brzezinski, C.

(1992). The effects of biofeedback-assisted relaxation on cell-mediated immunity, cortisol, and white blood cell count in healthy adult subjects. Journal of Behavioral Medicine, 15, 343-354.

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Reeves, W. H., Fisher, D. E., & Wisniewolski, R. (1986). Psoriasis and Raynaud's phenomena associated with autoantibodies to U1 and U2 small nuclear ribonucleoproteins. New England Joumal of Medicine, 315, 105-111.

Rook, A., & Dawber, R. (1982). Diseases of the hair and Scalp. Blackwell Scientific Publications, p. 277.

Schneck, J. M. (1966). Hypnotherapy for ichthyosis. Psychosomatics, 7, 233-235. Sedlacek, R. (1989). The Sedlacek technique. New York: McGraw-Hill. Shelley, W. B., & Shelley, E. D. (1985). Adrenergic urticaria: A new form of stress-induced

hives. Lancet, 1, 1031-1033. Whitlock, K. A. (1976). Psychophysiologic aspects of skin diseases. London: Saunders.