Role of anti-depressant fluoxetine in the puva treatment of psoriasis vulgaris

Introduction

Psoriasis is a common and chronic inflammatory and proliferative papulosquamous disease of the skin,[1] of unknown etiology.[2] It is characterized by sharply defined erythematous, scaly lesions particularly on the extensors of the body and scalp with frequent remissions and relapses affecting both sexes equally. The chronic course with intermittent exacerbation poses a great physical and mental stress to the patients. Again it is known that Psoriasis is made worse by stress in approximately 30 to 40 per cent of the cases.[3] When psoriasis starts worsening, patients are subjected to increased stress. Often they have been noted to be obsessed with the progressing condition of the disease and suffer from dysthymia and depression. So the role of antidepressant drug Fluoxetine was evaluated in this study.

Psoriasis causes psychological distress in patients undergoing PUVA treatment through its effects on the patient′s everyday life.[4] Also a statistically significant correlation was noted between the extent of Psoriasis and the proportion of patients stating their disease worsened at times of psychological stress.[5] Recently psychological intervention has proved to be a valuable adjunct to the normal dermatological treatment and was followed by improvement in the majority of the patients.[6] The importance of assessing the effects of psoriasis specific stress indicated the role of adjunctive psychosocial stress management training for a significant number of patients with psoriasis.[7] Depression and suicidal ideation have been noted in patients severely affected by psoriasis and their prevalence was higher than generalized medical patients.[8]

Fluoxetine is a well-established anti-depressant and is used for obsessive compulsive disorder too. However there is one report where two patients on long term Fluoxetine had developed psoriasis after six and twelve months of exposure.[9]

The present study was conducted to evaluate the role of Fluoxetine in reducing the psychological stress in psoriasis patients. Since psychic stress is associated with clinical severity and symptoms of psoriatic patients[10], therefore more attention to the mental well being should be considered in psoriatic patients seeking medical care.

Materials and Methods

Twenty patients of psoriasis vulgaris were included in the study. All the patients had more than 30% body area involvement and the disease was progressing rapidly. All the patients were suffering from severe stress due to progress of the disease. The study was randomized, double blinded, age and sex matched. In each case patients were assessed with PASI scoring. All patients were treated with PUVA therapy. Half of the patients were given capsule fluoxetine 20 mg. daily after breakfast whereas the other half were given placebo capsules. Assessment was done before starting treatment, then after every 5 PUVA treatments till 20 treatments were reached. Statistical analysis was done by SPSS 7.5 Statistical Analysis Software. Within group comparison was done by Wilcoxon Signed Ranks test while inter group comparison was done by Mann-Whitney U--test.

Results

The results were as follows:

1. Abbreviations:

ScTO = Score at 0 treatment

ScT5 = Score at 5 treatment

ScT10 = Score at 10 treatment

ScT15 = Score at 15 treatment

ScT20 = Score at 20 treatment

2. "FNx01" = p < 0.05 compared to baseline in respective group.

Addition of fluoxetine to PUVA has shown a trend towards more rapid improvement, but this fails to reach the level of statistical significance. Therefore a larger sample size may be considered. Individually in both groups there is statistically significant improvement right from the first 5 treatment sessions and is sustained thoughout the duration of treatment.

Discussion

The study showed that all the ten patients who had been prescribed fluoxetine along with PUVA therapy showed quicker improvement as compared to those with placebo and PUVA therapy. Hence, fluoxetine may be used as an adjunct in the treatment of psoriasis along with PUVA therapy. This may serve the double purpose of ameliorating psoriasis, as well as the psychological impact associated with it, thus improving the life quality of the patients. However, a more extensive study with a larger sample size is warranted to assess the statistical significance associated with it.