Complementary strategies in psoriasis - Non-pharmacological approaches for comprehensive management

Valenzuela, Fernando; Benavides, Eine; Echeverry, Esther Verónica; Hartmann, Dan; Bilicic, Daniza

doi:10.1016/j.abd.2026.501356

Abstract

Background: Psoriasis is a chronic immune-mediated inflammatory disease linked to sys-temic comorbidities such as obesity, diabetes, cardiovascular disease, and inflammatory bowel disease. Non-pharmacological interventions, such as dietary modifications, nutritional sup-plementation, exercise, and psychological interventions, have emerged as complementary therapies in the management of psoriasis.

Objectives: Review the current and recent evidence and the role of trace elements, vitamins, diet, exercise, and psychological interventions as complementary approaches in the manage-ment of patients with psoriasis.

Materials and methods: A narrative review was conducted, analyzing clinical trials, meta-analyses, and cohort studies from major databases.

Results: Trace elements such as zinc, copper, and selenium, and vitamins including D, E, B-complex, and A, play roles in oxidative stress modulation, immune regulation, and keratinocyte biology. However, the clinical efficacy of micronutrient supplementation remains uncertain due to inconsistent and conflicting findings. Dietary interventions, particularly Mediterranean diet adherence and weight loss through caloric restriction or bariatric surgery, have been associated with reductions in psoriasis severity, although clear clinical protocols are lacking. Aerobic exer-cise appears beneficial but is underutilized, partially due to psychological and disease-related barriers. Furthermore, psoriasis is associated with a high prevalence of psychological disorders, with the necessity to integrate psychological interventions to optimize disease management. Study limitations: The available evidence is limited and with heterogeneity in study design, with small sample sizes, observational methodologies, and inconsistent intervention protocols, restricting causal inference and generalizability.

Conclusion: While non-pharmacological strategies show promise as complementary interven-tions in psoriasis management, they cannot replace conventional therapy. Further studies are required to confirm their clinical impact. These approaches should be considered as comple-mentary strategies, with individualized patient assessments and continuous follow-up being essential.

KEYWORDS
Comorbidities; Complementary therapies; Diet; Mediterranean; Exercise; Psoriasis; Vitamins

Introduction

Psoriasis is a chronic inflammatory disease of immuno-logical origin, characterized by excessive activation of the Tumor Necrosis Factor-alpha (TNF-α)/Interleukin (IL)-23/IL-17 axis, leading to hyperproliferation and abnormal differentiation of epidermal keratinocytes. This condition is frequently associated with various comorbidities, includ-ing obesity, diabetes mellitus, dyslipidemia, cardiovascular diseases, and inflammatory bowel disease.¹ Patients with psoriasis often exhibit unbalanced dietary habits, with high-fat intake and low fiber consumption. In recent years, nutrition has been shown to play a key role in the devel-opment and progression of psoriatic disease, as well as in its associated comorbidities. This has led to a growing interest in the scientific literature regarding the use of nutri-tional supplements, such as trace elements and vitamins, in the treatment of psoriasis.² On the other hand, exer-cise also influences chronic inflammatory diseases, including psoriasis. Likewise, the presence of this disease can impact patients’ physical activity levels. Regular moderate to vigor-ous exercise has been found to be an independent preventive factor in reducing the risk of developing psoriasis. Moreover, in overweight patients, physical activity aimed at weight loss may improve disease severity. However, this population tends to be more sedentary and faces multiple barriers to engaging in exercise.³ Psoriasis is not merely a dermatolog-ical condition; it significantly impacts patients’ quality of life and mental health. Patients with psoriasis are 1.5 times more likely to present a mental illness, also a 12.7% can have suicidal ideations.⁴ Integrating cognitive-behavioral ther-apy, support groups, or other psychological interventions is also essential for a comprehensive disease management approach. In this study, the authors explore the impact of some of the most relevant nutrients in psoriasis, as well as the role of diet, exercise, and the evaluation of psychiatric conditions in its management and progression.

Materials and methods

This study is a narrative review evaluating the role of trace elements, vitamins, diet, exercise, and psychological inter-ventions in psoriasis pathophysiology and management. A systematic search was conducted in PubMed, Scopus, Web of Science, and Google Scholar databases, between March and April of 2025. Search terms included ‘‘Psoriasis AND trace elements (Zinc, Copper, Selenium)’’; ‘‘Psoriasis AND vita-mins (Vitamin D, Vitamin E, Vitamin A, Vitamin B complex)’’; ‘‘Psoriasis AND diet (Mediterranean diet, Caloric restric-tion, Micronutrient deficiencies)’’; ‘‘Psoriasis AND exercise (Physical activity, Weight loss, Obesity, Inflammation)’’; ‘‘Psoriasis AND bariatric surgery’’; ‘‘Psoriasis AND psycho-logical disorders (Depression, Anxiety, Quality of life)’’. Only studies published in English and Spanish were included.

Results

Psoriasis and trace elements

Zinc and copper

Zinc (Zn) is an essential cofactor in the catalytic activ-ity of over 200 enzymes, playing a crucial role in immune function, wound healing, protein synthesis, DNA synthe-sis, and cell division.⁵ It acts as a coenzyme for DNA and RNA polymerases and is important in the hyperprolifera-tion of keratinocytes observed in psoriasis skin, resulting in higher Zn consumption secondary to this accelerated cellular turnover in psoriasis, which may lead to a reduc-tion in serum levels.⁶ Conversely, Zn deficiency can lead to decreased enzymatic activity of key antioxidants and immune cell dysfunction, thereby increasing susceptibility to viral and bacterial infections that can exacerbate skin inflammation and trigger psoriatic lesions.⁷ Copper (Cu) is another essential trace element with redox properties that make it both physiologically beneficial and potentially cytotoxic.⁸ In serum, Cu primarily binds to a2-globulin to form ceruloplasmin, a major antioxidant protein involved in scavenging excess free radicals.⁷ Elevated serum Cu levels observed in patients with psoriasis may reflect an upregu-lation of ceruloplasmin in response to the OS caused by the chronic inflammation in psoriasis. However, free Cu can cat-alyze the formation of Reactive Oxygen Species (ROS), such as superoxide anions (O₂-), Hydrogen peroxide (H₂O₂), and Hydroxyl radicals (OH-) through the Fenton reaction, and contribute to cellular damage and inflammation.⁹ A 2021 case-control study involving 72 patients with psoriasis, cat-egorized by Psoriasis Area and Severity Index (PASI) score (Group T1: PASI < 10, mild psoriasis; Group T2: PASI > 10, severe psoriasis), reported that serum Cu levels and the Cu/Zn ratio in psoriatic patients compared to healthy con-trols were significantly higher.¹⁰ The serum Zn levels were not significantly different between the two groups, suggest-ing that the increase in the Cu/Zn ratio may be attributable to the increase in Cu rather than decreased Zn levels. A meta-analysis conducted between 1988 and 2016 supports these findings, with studies comparing serum Cu and Zn levels between psoriasis patients and healthy controls, and they observed elevated serum Cu levels and reduced serum Zn levels in patients with psoriasis.⁷ Moreover, research in patients with psoriatic arthritis has indicated that elevated Cu and reduced Zn levels may contribute to disease patho-genesis. Interestingly, one proposed mechanism underlying the therapeutic efficacy of methotrexate in psoriatic arthri-tis is its ability to increase serum Zn and reduce serum Cu concentrations.¹¹ In summary, although alterations in Zn and Cu levels are consistently observed in psoriatic and psoriatic arthritis, the clinical relevance of these findings and their potential utility as therapeutic targets remain unclear and require further investigation.

Selenium

Selenium (Se) is an essential element with antiproliferative and immunoregulatory properties. It has been proposed that Se contributes to psoriasis improvement by mitigating the OS, potentially through the upregulation of catalase and superoxide dismutase activity via its antioxidant effects.¹² Another hypothesis suggests that Se regulates immune processes in psoriasis, modulating cytokine expression, expressing inhibitory effects on TNF-α levels and promot-ing an increase in CD4+ T-cells populations in the reticular dermis of psoriatic lesions.¹³-¹⁶ Several studies have inves-tigated the relationship between Se levels and psoriasis severity. A 2002 study reported an inverse correlation between serum Se levels and psoriasis severity.¹⁴ A double-blind, placebo-controlled clinical trial comparing the effects of a combination therapy of Se aspartate, coenzyme Q10, and vitamin E versus placebo demonstrated significant improvement in PASI and Severity Score (SS) in patients with severe erythrodermic and arthropathic psoriasis.¹⁵ Consis-tent with these findings, other studies have observed that serum Se levels in patients with psoriasis tend to be lower compared to healthy controls, suggesting a possible link between Se deficiency, OS, and altered immune responses in the disease’s pathogenesis.¹⁶,¹⁷ However, evidence regard-ing the therapeutic efficacy of Se supplementation remains inconsistent. In a double-blind parallel-group study no added benefit of Se supplementation when its combined with nar-rowband UVB (NB-UVB) phototherapy compared to NB-UVB with placebo.¹⁸ Additionally, a case-control study conducted on hospitalized patients between January and June 2002, reported that selenomethionine supplementation was inef-fective as an adjunct treatment for plaque psoriasis, and Se supplementation might contribute to sustained eleva-tions in soluble TNF-α type 1 receptor in psoriasis patients, even after lesion remission.¹⁹ A 2012 meta-analysis rein-forced these mixed findings, with no statistically significant differences in serum Se levels between psoriasis patients and controls.²⁰ In summary, the role of Se in psoriasis appears to be multifactorial, involving potential contribu-tions to OS regulation, cytokine modulation, and immune system balance. Despite evidence supporting an associa-tion between low Se levels and disease severity, current data on its therapeutic application remain inconclusive. Fur-ther high-quality, controlled studies are necessary to clarify the mechanistic and clinical significance of Se in psoriasis management.

Psoriasis and vitamins

Vitamin D

Vitamin D (VD) plays a critical role in calcium-phosphorus homeostasis. Its prolonged deficiency leads to rickets in children and osteomalacia in adults. Beyond its skeletal effects, VD presents immunomodulatory functions, influenc-ing both innate and adaptive immune responses.²¹ Given its role in immune regulation and skin homeostasis, the association between VD status and psoriasis has been exten-sively investigated.²²-²⁶ Multiple studies have reported that patients with psoriasis present lower serum concentration of 25-Hydroxyvitamin D (25(OH)D) compared to healthy controls, suggesting a potential contributory role of VD defi-ciency in psoriasis pathogenesis.²³ However, interventional trials have yielded mixed results. Some randomized clinical trials evaluating oral VD supplementation have not demon-strated significant improvements in PASI scores, indicating that VD supplementation alone may not suffice to induce clinical remission.²⁴ Similarly, a study examining seasonal VD supplementation during winter failed to show significant changes in disease severity between treated and placebo groups.²⁵ An interventional cohort study evaluating NB-UVB therapy provides evidence that NB-UVB therapy can reduce VD-Binding Protein (DBP) and high-sensitivity C-Reactive Protein (hs-CRP) levels while increasing serum VD levels in psoriasis patients.²⁶ This suggests a potential systemic anti-inflammatory effect of phototherapy, particularly in VD-deficient patients. It has also been proposed that VD derivatives may enhance phototherapy efficacy in psoria-sis without causing adverse side effects.²²,²⁶ Additionally, a Mendelian randomization analysis has suggested a poten-tial protective effect of higher VD levels against psoriasis development, although further studies are needed to con-firm this relationship.²⁷ In summary, while VD appears to play a role in the pathogenesis and treatment response of psoriasis, current evidence does not support its routine use as a monotherapy. Regular monitoring of VD levels in pso-riasis patients is advisable, and supplementation should be considered in individuals with confirmed deficiency.

Vitamin E

Vitamin E (VE) is a lipophilic antioxidant that protects cel-lular membranes from oxidative damage, which has been implicated in the pathogenesis of inflammatory skin dis-eases, including psoriasis.²⁸ The relationship between VE and psoriasis has been explored in multiple studies. A meta-analysis demonstrated that serum VE levels are lower in psoriasis patients compared to healthy controls, suggesting that VE deficiency may predispose individuals to developing this immune-mediated disease.²⁹ Supporting this finding, a cross-sectional study based on data from the National Health and Nutrition Examination Survey (NHANES) found that higher dietary intakes of VE were inversely associated with the risk of psoriasis.³⁰ It has also been found that VE sup-plementation, in combination with other antioxidants such as coenzyme Q10 and Se, has improved clinical conditions in patients with severe forms of psoriasis, such as psori-atic arthritis and erythrodermic psoriasis.³¹ In conclusion, although current evidence indicates a potentially beneficial role of VE in psoriasis prevention and symptom modulation, additional high-quality clinical trials are required to estab-lish its efficacy and determine optimal dosing strategies. At present, VE may be considered as part of a comprehen-sive dietary and lifestyle approach to psoriasis management, rather than as a standalone therapeutic intervention.

Vitamin B

Cobalamin (vitamin B12) and folic acid (vitamin B9) have been implicated in the pathophysiology of psoriasis through their role in homocysteine metabolism. Hyperhomocysteine-mia in these patients has been related to VB9 and VB12 deficiency,³²,³³ and with immunoinflammatory processes by activation of Th1 and Th17 lymphocytes and suppressing T-reg cells.³⁴ A meta-analysis found that psoriasis patients exhibit higher homocysteine levels and a greater prevalence of hyperhomocysteinemia compared to controls; however, no significant differences in serum levels of VB12 were detected between the two groups.³² In contrast, another study reports a direct correlation between homocysteine levels and psoriasis severity, and an inverse relationship with folic acid levels.³⁵ In a study of 98 psoriasis patients and 98 controls, which found that 57% of psoriasis patients had elevated homocysteine levels compared to 25% in con-trols (p < 0.0001). These patients also had significantly lower serum vitamin B12 levels, though no direct association with PASI was observed.³⁶ Regarding vitamin B6, alterations in its metabolism have been suggested to influence skin inflam-mation, though further studies are required to confirm these findings.³⁷ In summary, there is growing evidence support-ing a connection between altered homocysteine metabolism and psoriasis, possibly mediated by deficiencies in VB9 and VB12. These alterations may contribute to both disease pathogenesis and its associated cardiovascular risks. While current findings highlight the potential value of assessing homocysteine and B-vitamin levels in psoriasis patients, more robust clinical trials are necessary before clear sup-plementation guidelines can be established.

Vitamin A

Vitamin A (VA) and its metabolites - such as retinoic acid and synthetic retinoid derivatives - have been used in the mana-gement of psoriasis with variable therapeutic outcomes. Retinoids influence keratinocyte proliferation, differentia-tion, and keratinization, processes that are dysregulated in psoriasis³⁸; VA is critical for maintaining epithelial integrity and modulating immune responses. The metabolism of VA is correlated to the CYP1A1 gene. A study comparing 45 pso-riasis patients and 45 healthy controls analyzed the CYP1A1 polymorphism (rs1048943) and serum VA levels. The AG genotype was found exclusively in psoriasis patients (22.2%, p = 0.001) and was associated with lower VA concentrations. Additionally, psoriasis patients had significantly reduced VA levels compared to controls (p < 0.001), suggesting that the CYP1A1 gene and VA deficiency may contribute to disease susceptibility and severity.³⁹ Controversy a NHANES analy-sis in the United States found that psoriasis patients had higher serum VA levels compared to healthy controls, sug-gesting a possible association between elevated VA levels and psoriasis.⁴⁰ However, these findings are inconsistent and require further investigation to determine the direc-tion and implications of this association. Retinoic acid has anti-inflammatory and immunoregulatory properties, which could improve clinical psoriasis lesions. And it exhibits fungistatic effects, which are particularly relevant for pso-riasis patients undergoing IL-17 inhibitor therapy, as such biologics may increase the risk of fungal infections.⁴¹ Topical formulations may offer a more favorable safety profile when combined with corticosteroids. Systemic retinoids, such as acitretin, have shown benefits in erythrodermic or pustular psoriasis, and have been used as an adjuvant treatment for generalized psoriasis to enhance the effects of anthralin, PUVA, or UVB therapy.³⁸ In summary, although vitamin A derivatives have shown therapeutic potential in psoria-sis by targeting keratinocyte function and inflammation, their clinical application is constrained by dose-dependent toxicity and variable patient response. The relationship between vitamin A levels, genetic polymorphisms, and pso-riasis pathogenesis remains incompletely understood and warrants further research. Currently, VA supplementation is not recommended as a standalone treatment, but retinoids may have a role in select clinical scenarios.

Psoriasis and exercise

Physical activity plays a crucial role in the prevention and management of chronic diseases, including inflammatory disorders, cardiovascular diseases, obesity, and metabolic syndrome.⁴² Psoriasis is associated with these comorbidi-ties, and both obesity and physical inactivity are recognized as significant risk factors for its development. Therefore, moderate-intensity exercise has been proposed as a com-plementary treatment for psoriasis patients.⁴³ The American Heart Association (AHA) recommend in all adults aged 18-65 years take part in moderate-intensity aerobic physical activ-ity for a minimum of 30 minutes on 5-days each week, or vigorous-intensity aerobic physical activity a minimum of 20-minutes on 3-days each week.⁴⁴ The HUNT study eval-uated the relationship between the Body Mass Index (BMI), waist circumference, waist-to-hip ratio, and 10-year weight changes on psoriasis risk. The study found a significant asso-ciation between an increase in body weight and psoriasis risk, particularly in individuals who gained 10 kg or more during the follow-up period. These findings highlight weight control as a potential preventive strategy for psoriasis.⁴⁵ It has been demonstrated that increased adipose tissue affects levels of inflammatory cytokines involved in psoriasis, such as TNF-α and IL-17. Since obesity is a risk factor for devel-oping or worsening psoriasis, physical activity may have a protective role against the disease.⁴⁶ A randomized clini-cal trial by Naldi et al. evaluated the impact of exercise in psoriasis patients with PASI > 10 and overweight or obe-sity. The study included 303 patients who performed aerobic exercise for at least 40-minutes, three times per week, for 20-weeks, aiming for a 5% weight reduction. The exercise group experienced a 48% PASI reduction, while the control group showed a 25.5% PASI reduction (p = 0.02).⁴⁷ A recent systematic review examined the role of physical activity in preventing and treating patients with psoriasis. The find-ings suggest that engaging in moderate intensity exercise can lead to improved antioxidant gene expression, reduced oxidative stress, higher levels of sex hormone-binding glob-ulin, and lower levels of Insulin-like Growth Factor 1 (IGF-1), along with a decrease in adipose tissue mass. These changes in metabolism and hormones help lower insulin and leptin levels, boost adiponectin levels, and ultimately reduce sys-temic inflammation.⁴⁸ A 2022 systematic review suggested that the beneficial effects of exercise on psoriasis may be mediated, in part, through adipose tissue reduction. However, psoriasis patients often report reduced physical activity levels, attributed to disease-related limitations such as skin discomfort, pain, or social stigma.⁴⁵ In another study that evaluated the barriers to physical activity in patients with chronic psoriasis, found that 53% of patients aged 18-65, and 66% of those over 65, did not meet recommended physical activity levels for cardiovascular health, the main key barriers were skin sensitivity and discomfort during exer-cise, embarrassment about the appearance of their skin, limitations in clothing choices (such as avoiding sportswear that exposes affected areas), and the impact of treatments interfering with exercise routines. The study also showed that greater disease severity and poorer dermatology-related quality of life (measured by the DLQI) were linked to lower physical activity levels, particularly in women aged 18-65.⁴⁹ In summary, physical activity may play a dual role in both psoriasis prevention and symptom improvement, par-ticularly among overweight or obese individuals. It should be considered as a complementary, non-pharmacological strat-egy within a multidisciplinary treatment approach. Also, healthcare professionals need to recognize and address the specific barriers that can restrict psoriasis patients from engaging in physical activity. Tailored interventions that accommodate the unique challenges faced by individuals with psoriasis are recommended to promote healthier, more active lifestyles.

Psoriasis and diet

The role of diet as a treatment for psoriasis has been evalu-ated in several studies, showing that a dietary intervention can reduce systemic inflammation through the intake of antioxidant and anti-inflammatory nutrients.⁵⁰ The current Western diet is considered pro-inflammatory, being rich in omega-6 fatty acids, high-calorie intake, and trans fats, and it may exacerbate immune dysregulation in psoriasis.⁵¹ In contrast, nutritional strategies that promote immune homeostasis, particularly the Mediterranean diet, rich in vegetables, fruits, whole grains, and healthy fats, have been associated with reduced incidence of metabolic and inflammatory disease and may offer a protective effect in psoriasis.⁵² Calorie-restricted diets have been shown to slightly reduce PASI scores and improve the quality of life in affected individuals.⁵³ Furthermore, diets high in fiber, vitamins, and polyphenols have demonstrated anti-inflammatory properties and may positively influence the gut microbiota, a factor increasingly recognized in psoria-sis pathophysiology.⁵³-⁵⁵ A comparative study of 45 psoriasis patients with 43 controls, revealing that psoriasis patients had higher BMI, LDL cholesterol, and total cholesterol levels, but lower HDL cholesterol levels. Additionally, they con-sumed more carbohydrates and fats, but less fiber, folate, and VE. These findings suggest that nutritional imbalances and dyslipidemia may contribute to disease severity, rein-forcing the importance of targeted dietary counseling in psoriasis management.⁵⁶ A meta-analysis found that weight loss through lifestyle interventions significantly improved psoriasis compared to control group interventions. Conse-quently, it has been suggested that, in combination with conventional therapy, an appropriate diet should be imple-mented to enhance clinical responses in psoriasis and reduce comorbidities.⁵⁷

Psoriasis and bariatric surgery

Bariatric surgeries, including procedures such as sleeve gastrectomy and gastric bypass, have emerged as a poten-tial complementary therapy in obese psoriasis patients. A recent observational study of 32 patients undergoing bariatric surgery reported a significant reduction in PASI score after the surgical intervention.⁵⁸ In another study involving 10 obese psoriasis patients, 70% remained in remis-sion for at least six months following surgery, and three out of four patients on systemic therapy discontinued med-ication due to significant improvement. Improvements in quality of life and reduction in cardiovascular risk factors were also observed.⁵⁹ However, bariatric surgery is associ-ated with an increased risk of micronutrient deficiencies, including VD, VB12, iron, calcium, Se, Zn, among others, due to altered nutrient absorption post-surgery.⁶⁰-⁶³ These deficiencies can lead to anemia, osteoporosis, neurological complications, and potentially exacerbate psoriasis symp-toms. For example, selenium deficiency has been linked to muscle weakness, cardiomyopathy, and psoriasis flares.⁶³,⁶⁴ Despite the widespread use of multivitamin and mineral supplements, nutrient deficiencies persist in a consider-able percentage of patients, highlighting the need for continuous evaluation.⁶³,⁶⁵ In conclusion, weight reduction strategies, including diet and bariatric surgery, may offer substantial benefits in psoriasis - particularly among obese patients. Nevertheless, these interventions require careful patient selection and a comprehensive risk-benefit eval-uation, given the potential for long-term metabolic and nutritional complications.

Psoriasis and mental health

It’s clear that psoriasis is associated impacts in patients’ quality of life and mental health. The presence of depres-sion, anxiety, and social stigma is well-documented in psoriasis patients. In a systematic review of anxiety disor-ders in patients with psoriasis was 7%-48%.⁶⁶ In the case of depression, the prevalence is estimated to 20%-30%.⁶⁷ The association with other psychiatric conditions has been described, such as schizophrenia, bipolar disorder, and post-traumatic stress disorder.⁴ The suicidal ideation in patients with psoriasis has been reported in a 12.7% of the patients.⁶⁸ The higher presence of proinflammatory markers has been correlated with elevated risk of depression, anxiety, and schizophrenia in patients with psoriasis, suggesting a nexus with the neuroinflammatory pathways and the severity of lesions in the skin.⁶⁹ In the other hand, social stigma affects patients with psoriasis, potentially leading to worsened symptoms or difficulty engaging in physical activity.⁷⁰,⁷¹ In patients with psoriasis, a screening for depression, anxi-ety, and suicidality should be made, and the evaluation of other psychiatric conditions. Addressing stress, depression, or anxiety can improve the overall health and quality of life of patients, reducing the severity of skin lesion, the consid-eration of behavioral interventions or Cognitive-Behavioral Therapy (CBT) might aid in improving adherence to dietary changes and exercise programs.

Discussion

Psoriasis is an immune-mediated inflammatory chronic disease caused by a complex interplay of genetic, environ-mental, and lifestyle factors.¹ Emerging evidence highlights the role of nutrition, physical activity, and specific micronu-trients in modulating the disease course and associated comorbidities.³¹

For instance, Se shows potential due to its antioxidant and immunoregulatory functions; studies report inconsis-tent outcomes, with some suggesting clinical improvements and others finding no significant effect.²⁰ VD deficiency is frequent in psoriasis patients, yet supplementation alone has not consistently translated into clinical improvement, possibly due to differences in baseline levels, dosing, or concurrent therapies.²⁷ Similar ambiguities surround VE, with a lack of definitive evidence for its use as a monotherapy. The relationship between elevated homocys-teine and psoriasis implicates deficiencies in vitamin B12 and folic acid. Although some studies demonstrate correla-tions with disease severity and cardiovascular risk, direct benefits from supplementation remain uncertain.³²,³³ Vita-min A and its derivatives have shown efficacy in certain psoriasis subtypes but are limited by their toxicity pro-files. Genetic polymorphisms influencing VA metabolism may further affect individual responses.³⁹ Exercise and dietary interventions offer promising adjunctive benefits. Structured aerobic exercise has demonstrated improve-ments in PASI scores and metabolic parameters,⁴⁷ yet patient adherence may be hindered by disease-related physical or psychological barriers.⁴⁹ Similarly, while anti-inflammatory diets - particularly the Mediterranean diet - are associated with symptom improvement, adherence and long-term outcomes require further validation.⁵² Caloric restriction and nutrient-rich diets improve quality of life and inflammation, but need standardization in clinical recom-mendations. Bariatric surgery provides significant benefits for obese psoriasis patients, including symptom remis-sion and medication reduction. However, the procedure is associated with long-term micronutrient deficiencies (e.g., VD, Se, B12), necessitating careful post-operative monitoring.⁶²,⁶³ The limited sample sizes and observational nature of current studies also limit the strength of conclu-sions. Psoriasis significantly impacts mental health, with a high prevalence of anxiety, depression, and even suici-dal ideation.⁴ It is also associated with other psychiatric disorders and inflammatory processes.⁶⁹ Additionally, social stigma can worsen symptoms. Therefore, psychological sup-port and interventions like cognitive-behavioral therapy are essential.

Despite promising associations, several limitations con-strain the current body of research. Firstly, many studies cited are observational or cross-sectional, which lim-its causal inference. Randomized controlled trials remain scarce or yield mixed results, particularly for micronutri-ent supplementation. Variability in study design, sample sizes, disease severity, and intervention protocols further complicates data interpretation. Additionally, heterogene-ity in patient populations, such as age, BMI, comorbidities, and baseline nutrient levels, affects generalizability. Con-founding factors such as medication use, dietary patterns, and lifestyle behaviors are often inadequately controlled. Future research should prioritize randomized controlled trials, standardized protocols for dietary, exercise, and psy-chological interventions, and integration of psychosocial support into psoriasis management strategies.

In summary, while the role of nutrition and lifestyle in psoriasis management is gaining recognition, the cur-rent evidence is insufficient to establish universal clinical guidelines. Individualized strategies focusing on weight management, balanced nutrition, and regular moderate-intensity physical activity hold promise in enhancing treatment outcomes and quality of life for patients with psoriasis.

Conclusion

There is evidence suggesting an interaction between trace elements, vitamins, diet, exercise, and psychological sup-port with psoriasis. This information offers promising complementary strategies for psoriasis management. How-ever, given the variability and inconsistency of the current evidence, these approaches should not substitute for estab-lished treatments. Further studies and research are needed to clarify these relationships and aim to develop clear clini-cal guidelines and integrate psychological considerations to optimize outcomes in psoriasis patients.

Financial support

None declared.

Research data availability

Does not apply.

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²⁷ Ren Y, Liu J, Li W, Zheng H, Dai H, Qiu G, et al. Causal associa-tions between vitamin D levels and psoriasis, atopic dermatitis, and vitiligo: a bidirectional two-sample Mendelian randomiza-tion analysis. Nutrients. 2022;14:5284.
²⁸ Berardesca E, Cameli N. Vitamin E supplementation in inflam-matory skin diseases. Dermatol Ther. 2021;34:e15160.
²⁹ Liu X, Yang G, Luo M, Lan Q, Shi X, Deng H, et al. Niveles séri-cos de vitamina E y enfermedades inflamatorias crónicas de la piel: una revisión sistemática y un metanálisis. PLoS One. 2021;16:e0261259.
³⁰ Song B, Liu W, Du L, Li X, Duan Y. The association of psoriasis with composite dietary antioxidant index and its components: a cross-sectional study from the national health and nutrition examination survey. Nutr Metab (Lond). 2024; 21:76.
³¹ Garbicz J, Całyniuk B, Górski M, Buczkowska M, Piecuch M, Kulik A, et al. Nutritional therapy in persons suffering from psoriasis. Nutrients. 2021;14:119.
³² Tsai TY, Yen H, Huang YC. Serum homocysteine, folate and vita-min B12 levels in patients with psoriasis: a systematic review and meta-analysis. Br J Dermatol. 2019;180:382-9.
³³ Lin X, Meng X, Song Z. Homocysteine and psoriasis. Biosci Rep. 2019;39:BSR20190867.
³⁴ Barberis M, Rojas López A. Metabolic imbalance driving immune cell phenotype switching in autoimmune disorders: tipping the balance of T- and B-cell interactions. Clin Transl Med. 2024;14:e1626.
³⁵ Çakmak SK, Gül Ü, Kılıç C, Gönül M, Soylu S, Kılıç A. Homocys-teine, vitamin B12 and folic acid levels in psoriasis patients. J Eur Acad Dermatol Venereol. 2009;23:300-3.
³⁶ Brazzelli V, Grasso V, Fornara L, Moggio E, Gamba G, Villani S, et al. Homocysteine, vitamin B12 and folic acid levels in psoriatic patients and correlation with disease severity. Int J Immunopathol Pharmacol. 2010;23:911-6.
³⁷ Martínez-Navarro FJ, Martínez-Morcillo FJ, López-Mun˜oz A, Pardo-Sánchez I, Martínez-Menchón T, Corbalán-Vélez R, et al. The vitamin B6-regulated enzymes PYGL and G6PD fuel NADPH oxidases to promote skin inflammation. Dev Comp Immunol. 2020;108:103666.
³⁸ Orfanos CE, Pullmann H, Runne U, Kurka M, Strunk V, Künzig M, et al. Behandlung der Psoriasis mit Vitamin A, Vitamin-A-Säure und oralen Retinoiden [Treatment of psoriasis using vitamin A, vitamin A acid and oral retinoids]. Hautarzt. 1979;30:124-33. German.
³⁹ Bazid HAS, Marae A, Tayel N, Serag E, Selim H, Mostafa MI, et al. Assessment of cytochrome P450 1A1 gene polymorphism and vitamin A serum level in psoriasis vulgaris. J Immunoassay Immunochem. 2023;44:269-82.
⁴⁰ Johnson JA, Ma C, Kanada KN, Armstrong AW. Diet and nutri-tion in psoriasis: analysis of the national health and nutrition examination survey (NHANES) in the United States. J Eur Acad Dermatol Venereol. 2014;28:327-32.
⁴¹ Campione E, Cosio T, Lanna C, Mazzilli S, Ventura A, Dika E, et al. Predictive role of vitamin A serum concentration in pso-riatic patients treated with IL-17 inhibitors to prevent skin and systemic fungal infections. J Pharmacol Sci. 2020;144: 52-6.
⁴² Nystoriak MA, Bhatnagar A. Cardiovascular effects and benefits of exercise. Front Cardiovasc Med. 2018;5:135.
⁴³ Yeroushalmi S, Hakimi M, Chung M, Bartholomew E, Bhutani T, Liao W. Psoriasis and exercise: a review. Psoriasis (Auckl). 2022;12:189-97.
⁴⁴ Haskell WL, Lee IM, Pate RR, Powell KE, Blair SN, Franklin BA, et al. American College of Sports Medicine; American Heart Association. Physical activity and public health: updated rec-ommendation for adults from the american college of sports medicine and the american heart association. Circulation. 2007;116:1081-93.
⁴⁵ Snekvik I, Smith CH, Nilsen TIL, Langan SM, Modalsli EH, Romundstad PR, et al. Obesity, waist circumference, weight change, and risk of incident psoriasis: prospective data from the HUNT study. J Invest Dermatol. 2017;137:2484-90.
⁴⁶ Jensen P, Skov L. Psoriasis and obesity. Dermatology. 2016;232:633-9.
⁴⁷ Naldi L, Conti A, Cazzaniga S, atrizi A, Pazzaglia M, Lanzoni A, et al. Diet and physical exercise in psoriasis: a randomized controlled trial. Br J Dermatol. 2014;170:634-42.
⁴⁸ 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;15:840.
⁴⁹ Auker L, Cordingley L, Pye SR, Griffiths CEM, Young HS. What are the barriers to physical activity in patients with chronic plaque psoriasis? Br J Dermatol. 2020;183:1094-102.
⁵⁰ Katsimbri P, Korakas E, Kountouri A, Ikonomidis I, Tsougos E, Vla-chos D, et al. The effect of antioxidant and anti-inflammatory capacity of diet on psoriasis and psoriatic arthritis phenotype: nutrition as therapeutic tool? Antioxidants (Basel). 2021;10: 157.
⁵¹ Neustadt J. Western diet and inflammation. Integr Med. 2006;5:14-8.
⁵² Abrignani V, Salvo A, Pacinella G, Tuttolomondo A. The Mediterranean diet, its microbiome connections, and cardio-vascular health: a narrative review. Int J Mol Sci. 2024;25: 4942.
⁵³ Cintoni M, Palombaro M, Maramao FS, Raoul P, Egidi G, Leonardi E, et al. Metabolic disorders and psoriasis: explor-ing the role of nutritional interventions. Nutrients. 2023;15: 3876.
⁵⁴ Secchiero P, Rimondi E, Marcuzzi A, Longo G, Papi C, Manfre-dini M, et al. Metabolic syndrome and Psoriasis: pivotal roles of chronic inflammation and gut microbiota. Int J Mol Sci. 2024;25:8098.
⁵⁵ Mahil SK, McSweeney SM, Kloczko E, McGowan B, Barker JN, Smith CH. Does weight loss reduce the severity and incidence of psoriasis or psoriatic arthritis? a critically appraised topic. Br J Dermatol. 2019;181:946-53.
⁵⁶ Yazdanpanah MJ, Vahabi-Amlashi S, Nematy M, Shaelaei N, Mohajeri SAR, Tafazzoli Z. Association of serum lipid profiles and dietary intakes of vitamin E and fiber with psoriasis severity. Caspian J Intern Med. 2021;12:606-12.
⁵⁷ Wu Z, Gao Z, Qiao Y, Chen F, Guan B, Wu L, et al. Long-term results of bariatric surgery in adolescents with at least 5 years of follow-up: a systematic review and meta-analysis. Obes Surg. 2023;33:1730-45.
⁵⁸ Hosseininasab A, Mosavari H, Rostami A, Bahardoust M, Izadi A, Jaliliyan A, et al. The long-term impact of bariatric surgery on psoriasis symptoms and severity: a prospective observational study. Surg Obes Relat Dis. 2024;20:1208-13.
⁵⁹ Farias MM, Achurra P, Boza C, Vega A, de la Cruz C. Psoriasis following bariatric surgery: clinical evolution and impact on quality of life on 10 patients. Obes Surg. 2012;22: 877-80.
⁶⁰ Styne DM, Arslanian SA, Connor EL, Farooqi IS, Murad MH, Silver-stein JH, et al. Pediatric obesity - assessment, treatment, and prevention: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2017;102:709-57.
⁶¹ Lombardo M, Franchi A, Biolcati Rinaldi R, Rizzo G, D’Adamo M, Guglielmi V, et al. Long-term iron and vitamin B12 deficiency are present after bariatric surgery, despite the widespread use of supplements. Int J Environ Res Public Health. 2021;18: 4541.
⁶² Shahmiri SS, Eghbali F, Ismaeil A, Gholizadeh B, Khalooei-fard R, Valizadeh R, et al. Selenium deficiency after bariatric surgery, incidence and symptoms: a systematic review and meta-analysis. Obes Surg. 2022;32:1719-25.
⁶³ Gasmi A, Bjørklund G, Mujawdiya PK, Semenova Y, Dosa A, Pis-copo S, et al. Dietary supplements and bariatric surgery. Crit Rev Food Sci Nutr. 2023;63:7477-88.
⁶⁴ Aaseth JO, Alexander J. Postoperative Osteoporosis in sub-jects with morbid obesity undergoing bariatric surgery with gastric bypass or sleeve gastrectomy. Nutrients. 2023;15: 1302.
⁶⁵ Antoine D, Li Z, Quilliot D, Sirveaux MA, Meyre D, Mangeon A, et al. Medium term post-bariatric surgery deficit of vita-min B12 is predicted by deficit at time of surgery. Clin Nutr. 2021;40:87-93.
⁶⁶ Fleming P, Bai JW, Pratt M, Sibbald C, Lynde C, Gulliver WP. The prevalence of anxiety in patients with psoriasis: a systematic review of observational studies and clinical trials. J Eur Acad Dermatol Venereol. 2017;31:798-807.
⁶⁷ Mrowietz U, Sümbül M, Gerdes S. Depression, a major comorbid-ity of psoriatic disease, is caused by metabolic inflammation. J Eur Acad Dermatol Venereol. 2023;37:1731-8.
⁶⁸ Gupta MA, Pur DR, Vujcic B, Gupta AK. Suicidal behaviors in the dermatology patient. Clin Dermatol. 2017;35:302-11.
⁶⁹ Hołdrowicz A, Z^˙ebrowska A. Molecular link between psoriasis and depression-update on pathophysiology. Int J Mol Sci. 2025;26:2467.
⁷⁰ Sahi FM, Masood A, Danawar NA, Mekaiel A, Malik BH. Associ-ation between psoriasis and depression: a traditional review. Cureus. 2020;12:e9708.
⁷¹ Barankin B, DeKoven J. Psychosocial effect of common skin dis-eases. Can Fam Physician. 2002;48:712-6.

Edited by

Editor
Sílvio Alencar Marques.

Publication Dates

Publication in this collection
31 July 2026
Date of issue
2026

History

Received
18 Nov 2025
Accepted
05 Jan 2026
Published
02 May 2026

This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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[28] ²⁸ Berardesca E, Cameli N. Vitamin E supplementation in inflam-matory skin diseases. Dermatol Ther. 2021;34:e15160.

[29] ²⁹ Liu X, Yang G, Luo M, Lan Q, Shi X, Deng H, et al. Niveles séri-cos de vitamina E y enfermedades inflamatorias crónicas de la piel: una revisión sistemática y un metanálisis. PLoS One. 2021;16:e0261259.

[30] ³⁰ Song B, Liu W, Du L, Li X, Duan Y. The association of psoriasis with composite dietary antioxidant index and its components: a cross-sectional study from the national health and nutrition examination survey. Nutr Metab (Lond). 2024; 21:76.

[31] ³¹ Garbicz J, Całyniuk B, Górski M, Buczkowska M, Piecuch M, Kulik A, et al. Nutritional therapy in persons suffering from psoriasis. Nutrients. 2021;14:119.

[32] ³² Tsai TY, Yen H, Huang YC. Serum homocysteine, folate and vita-min B12 levels in patients with psoriasis: a systematic review and meta-analysis. Br J Dermatol. 2019;180:382-9.

[33] ³³ Lin X, Meng X, Song Z. Homocysteine and psoriasis. Biosci Rep. 2019;39:BSR20190867.

[34] ³⁴ Barberis M, Rojas López A. Metabolic imbalance driving immune cell phenotype switching in autoimmune disorders: tipping the balance of T- and B-cell interactions. Clin Transl Med. 2024;14:e1626.

[35] ³⁵ Çakmak SK, Gül Ü, Kılıç C, Gönül M, Soylu S, Kılıç A. Homocys-teine, vitamin B12 and folic acid levels in psoriasis patients. J Eur Acad Dermatol Venereol. 2009;23:300-3.

[36] ³⁶ Brazzelli V, Grasso V, Fornara L, Moggio E, Gamba G, Villani S, et al. Homocysteine, vitamin B12 and folic acid levels in psoriatic patients and correlation with disease severity. Int J Immunopathol Pharmacol. 2010;23:911-6.

[37] ³⁷ Martínez-Navarro FJ, Martínez-Morcillo FJ, López-Mun˜oz A, Pardo-Sánchez I, Martínez-Menchón T, Corbalán-Vélez R, et al. The vitamin B6-regulated enzymes PYGL and G6PD fuel NADPH oxidases to promote skin inflammation. Dev Comp Immunol. 2020;108:103666.

[38] ³⁸ Orfanos CE, Pullmann H, Runne U, Kurka M, Strunk V, Künzig M, et al. Behandlung der Psoriasis mit Vitamin A, Vitamin-A-Säure und oralen Retinoiden [Treatment of psoriasis using vitamin A, vitamin A acid and oral retinoids]. Hautarzt. 1979;30:124-33. German.

[39] ³⁹ Bazid HAS, Marae A, Tayel N, Serag E, Selim H, Mostafa MI, et al. Assessment of cytochrome P450 1A1 gene polymorphism and vitamin A serum level in psoriasis vulgaris. J Immunoassay Immunochem. 2023;44:269-82.

[40] ⁴⁰ Johnson JA, Ma C, Kanada KN, Armstrong AW. Diet and nutri-tion in psoriasis: analysis of the national health and nutrition examination survey (NHANES) in the United States. J Eur Acad Dermatol Venereol. 2014;28:327-32.

[41] ⁴¹ Campione E, Cosio T, Lanna C, Mazzilli S, Ventura A, Dika E, et al. Predictive role of vitamin A serum concentration in pso-riatic patients treated with IL-17 inhibitors to prevent skin and systemic fungal infections. J Pharmacol Sci. 2020;144: 52-6.

[42] ⁴² Nystoriak MA, Bhatnagar A. Cardiovascular effects and benefits of exercise. Front Cardiovasc Med. 2018;5:135.

[43] ⁴³ Yeroushalmi S, Hakimi M, Chung M, Bartholomew E, Bhutani T, Liao W. Psoriasis and exercise: a review. Psoriasis (Auckl). 2022;12:189-97.

[44] ⁴⁴ Haskell WL, Lee IM, Pate RR, Powell KE, Blair SN, Franklin BA, et al. American College of Sports Medicine; American Heart Association. Physical activity and public health: updated rec-ommendation for adults from the american college of sports medicine and the american heart association. Circulation. 2007;116:1081-93.

[45] ⁴⁵ Snekvik I, Smith CH, Nilsen TIL, Langan SM, Modalsli EH, Romundstad PR, et al. Obesity, waist circumference, weight change, and risk of incident psoriasis: prospective data from the HUNT study. J Invest Dermatol. 2017;137:2484-90.

[46] ⁴⁶ Jensen P, Skov L. Psoriasis and obesity. Dermatology. 2016;232:633-9.

[47] ⁴⁷ Naldi L, Conti A, Cazzaniga S, atrizi A, Pazzaglia M, Lanzoni A, et al. Diet and physical exercise in psoriasis: a randomized controlled trial. Br J Dermatol. 2014;170:634-42.

[48] ⁴⁸ 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;15:840.

[49] ⁴⁹ Auker L, Cordingley L, Pye SR, Griffiths CEM, Young HS. What are the barriers to physical activity in patients with chronic plaque psoriasis? Br J Dermatol. 2020;183:1094-102.

[50] ⁵⁰ Katsimbri P, Korakas E, Kountouri A, Ikonomidis I, Tsougos E, Vla-chos D, et al. The effect of antioxidant and anti-inflammatory capacity of diet on psoriasis and psoriatic arthritis phenotype: nutrition as therapeutic tool? Antioxidants (Basel). 2021;10: 157.

[51] ⁵¹ Neustadt J. Western diet and inflammation. Integr Med. 2006;5:14-8.

[52] ⁵² Abrignani V, Salvo A, Pacinella G, Tuttolomondo A. The Mediterranean diet, its microbiome connections, and cardio-vascular health: a narrative review. Int J Mol Sci. 2024;25: 4942.

[53] ⁵³ Cintoni M, Palombaro M, Maramao FS, Raoul P, Egidi G, Leonardi E, et al. Metabolic disorders and psoriasis: explor-ing the role of nutritional interventions. Nutrients. 2023;15: 3876.

[54] ⁵⁴ Secchiero P, Rimondi E, Marcuzzi A, Longo G, Papi C, Manfre-dini M, et al. Metabolic syndrome and Psoriasis: pivotal roles of chronic inflammation and gut microbiota. Int J Mol Sci. 2024;25:8098.

[55] ⁵⁵ Mahil SK, McSweeney SM, Kloczko E, McGowan B, Barker JN, Smith CH. Does weight loss reduce the severity and incidence of psoriasis or psoriatic arthritis? a critically appraised topic. Br J Dermatol. 2019;181:946-53.

[56] ⁵⁶ Yazdanpanah MJ, Vahabi-Amlashi S, Nematy M, Shaelaei N, Mohajeri SAR, Tafazzoli Z. Association of serum lipid profiles and dietary intakes of vitamin E and fiber with psoriasis severity. Caspian J Intern Med. 2021;12:606-12.

[57] ⁵⁷ Wu Z, Gao Z, Qiao Y, Chen F, Guan B, Wu L, et al. Long-term results of bariatric surgery in adolescents with at least 5 years of follow-up: a systematic review and meta-analysis. Obes Surg. 2023;33:1730-45.

[58] ⁵⁸ Hosseininasab A, Mosavari H, Rostami A, Bahardoust M, Izadi A, Jaliliyan A, et al. The long-term impact of bariatric surgery on psoriasis symptoms and severity: a prospective observational study. Surg Obes Relat Dis. 2024;20:1208-13.

[59] ⁵⁹ Farias MM, Achurra P, Boza C, Vega A, de la Cruz C. Psoriasis following bariatric surgery: clinical evolution and impact on quality of life on 10 patients. Obes Surg. 2012;22: 877-80.

[60] ⁶⁰ Styne DM, Arslanian SA, Connor EL, Farooqi IS, Murad MH, Silver-stein JH, et al. Pediatric obesity - assessment, treatment, and prevention: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2017;102:709-57.

[61] ⁶¹ Lombardo M, Franchi A, Biolcati Rinaldi R, Rizzo G, D’Adamo M, Guglielmi V, et al. Long-term iron and vitamin B12 deficiency are present after bariatric surgery, despite the widespread use of supplements. Int J Environ Res Public Health. 2021;18: 4541.

[62] ⁶² Shahmiri SS, Eghbali F, Ismaeil A, Gholizadeh B, Khalooei-fard R, Valizadeh R, et al. Selenium deficiency after bariatric surgery, incidence and symptoms: a systematic review and meta-analysis. Obes Surg. 2022;32:1719-25.

[63] ⁶³ Gasmi A, Bjørklund G, Mujawdiya PK, Semenova Y, Dosa A, Pis-copo S, et al. Dietary supplements and bariatric surgery. Crit Rev Food Sci Nutr. 2023;63:7477-88.

[64] ⁶⁴ Aaseth JO, Alexander J. Postoperative Osteoporosis in sub-jects with morbid obesity undergoing bariatric surgery with gastric bypass or sleeve gastrectomy. Nutrients. 2023;15: 1302.

[65] ⁶⁵ Antoine D, Li Z, Quilliot D, Sirveaux MA, Meyre D, Mangeon A, et al. Medium term post-bariatric surgery deficit of vita-min B12 is predicted by deficit at time of surgery. Clin Nutr. 2021;40:87-93.

[66] ⁶⁶ Fleming P, Bai JW, Pratt M, Sibbald C, Lynde C, Gulliver WP. The prevalence of anxiety in patients with psoriasis: a systematic review of observational studies and clinical trials. J Eur Acad Dermatol Venereol. 2017;31:798-807.

[67] ⁶⁷ Mrowietz U, Sümbül M, Gerdes S. Depression, a major comorbid-ity of psoriatic disease, is caused by metabolic inflammation. J Eur Acad Dermatol Venereol. 2023;37:1731-8.

[68] ⁶⁸ Gupta MA, Pur DR, Vujcic B, Gupta AK. Suicidal behaviors in the dermatology patient. Clin Dermatol. 2017;35:302-11.

[69] ⁶⁹ Hołdrowicz A, Z^˙ebrowska A. Molecular link between psoriasis and depression-update on pathophysiology. Int J Mol Sci. 2025;26:2467.

[70] ⁷⁰ Sahi FM, Masood A, Danawar NA, Mekaiel A, Malik BH. Associ-ation between psoriasis and depression: a traditional review. Cureus. 2020;12:e9708.

[71] ⁷¹ Barankin B, DeKoven J. Psychosocial effect of common skin dis-eases. Can Fam Physician. 2002;48:712-6.