238: Inflammatory Connection Between Psoriasis + Depression w/ Fabrizio Galimberti, MD, PhD

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Psoriasis can be a very isolating condition that causes a lot of shame. My guest today will discuss how and why psoriasis can affect mental health and even lead to depression.

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My guest today, Dr. Fabrizio Galimberti, completed his medical training at Cleveland Clinic Lerner College of Medicine-Case Western Reserve University, received his doctorate degree from Dartmouth College and his residency at the Jackson Memorial Hospital-University of Miami Miller School of Medicine where he also served as chief resident.

Dr. Galimberti's research interests include oncodermatology, autoimmune connective tissue diseases, and impact on quality of life of dermatologic conditions.

He has published numerous articles in prestigious journals as well as presented his work at international conferences.

Join us as we discuss the connection between psoriasis and depression.

Has psoriasis affected your mental health? Let me know in the comments!

In this episode:

  • How does psoriasis affect quality of life?
  • Does psoriasis affect how people see themselves?
  • Ways psoriatic arthritis affects quality of life
  • The connection between psoriasis and depression
  • Benefits of being active and getting outside if you have psoriasis


“Genital psoriasis is something that it even leads to lower quality of life, and even more sensation of stigma. These patients do not want to have sexual intercourse with their partners, or they stop seeking out for partners because they're embarrassed or because they feel that they're going to be judged because of that rash.” [5:26]

“Musical therapy has been shown in multiple studies to help improve the skin clearance in psoriasis.” [20:13]


Dr. Galiberti's medical practice

237: Inflammatory Connection Between Psoriasis + Depression w/ Fabrizio Galimberti, MD, PhD FULL TRANSCRIPT

Jennifer: Dr. Galimberti, thank you so much for being here today. I loved your presentation at the Integrative Dermatology Symposium, and so it was a real honor that you were willing to come and share some of this information with my audience. So thank you for being here.

Dr. Galimberti: Oh, it is absolutely my pleasure. Thank you for inviting me. I actually really like your podcast, and I had a chance to listen to quite a few of those talks. So it's quite an honor for me to be here.

Jennifer: Is it safe to say that your specialty is psoriasis, or do you work with a lot of different dermatologic conditions?

Dr. Galimberti: So I mostly work with inflammatory conditions, probably the most common one is psoriasis. The second most common one being atopic dermatitis, but this group of conditions where the patients have skin manifestations, but then they have much more than skin manifestations, they might have a rash of course, but then they also might have GI issues, issues with digestion. They might have hair issues. They might have depression or quality of life issues, which I think is what we're going to be talking about.

Jennifer: Yeah, and I wanted to ask you about that. So I think we use terms sometimes where people… Like quality of life, I think sometimes feels a little vague to someone who's actually going through psoriasis. So, what do you find in terms of the research and also working clinically with psoriatic patients in terms of quality of life? And how is it impacted by psoriasis?

Dr. Galimberti: I agree with you. The term quality of life is an elusive term. It means so many different things for each one of us. What's interesting is that as physicians though, we do need to somewhat summarizing with data. So that's how we do our studies. So throughout the last few years, lots of scales have been developed, trying to give a number to quality of life.

Dr. Galimberti: And most of them are personal feelings. How do you feel about your social life? How do you feel about your love life? How do you feel about the quality of your sleep? Overall, what's really important is that it really depends from the patient, and each individual patient needs to be addressed differently when it comes to quality of life.

Dr. Galimberti: And I think that's particularly important for the conditions that I see, which are these inflammatory conditions, because independent of which one we're going to be talking about today, even though we're going to be focusing on psoriasis today, all of these skin conditions have been associated with a decreased quality of life. So that means that the patients are less happy overall about how they feel about themselves, but also how they feel about society sees them, and how they feel like their love, personal life, their social life is evolving with time.

Jennifer: And so with that being said, because I mean, it really is awful, especially when there's pain associated with the skin condition or it's in areas where it's incredibly embarrassing, especially… You can cover up lesions on your arms. You could cover-up. Well, you're in Miami. So it might be a little bit more difficult being that you're in a warmer climate to stay completely covered.

Jennifer: I live up in the Northeast, it's wintertime, and so wearing a turtleneck and full sleeves and pants is not abnormal, but for somebody who experiences this say, on their hands or on their face, or it starts to get into even the joints, there can be a lot of pain emotionally, physically associated with this. So does the disease of psoriasis, do you find that it impacts how someone sees themself?

Jennifer: Do they see themselves the same as other individuals without the disease, or does something happen to the way that they relate to themselves? And yeah, that relationship with yourself is so important. So share a little bit about your thoughts on that.

Dr. Galimberti: It's a good point. So psoriasis does impact not only how you feel in terms of how happy you are, but just as important here related to that, it impacts how you think about yourself. And that's the idea of stigma. The idea is that when you look at your skin and this is particularly true, as you pointed out for patients who psoriasis is visible for other people, no matter what you do, if it's in your hands, you might not want to shake somebody else's hands.

Dr. Galimberti: If it's on your scalp and it's scaly, people will see. It's going to be hard to cover. In these patients, particularly these patients for whom the psoriasis is very noticeable, these patients see themselves as somebody who's being judged. Independent on whether they're being judged or not. Now, this is particularly true for the pediatric population. Now, we always think of psoriasis as a disease of the adults, but unfortunately, there is a subset of patients who started developing psoriasis at a young age.

Dr. Galimberti: And particularly, these younger patients are even more sensitive to how they see themselves because they might not have experienced any stigma, but nonetheless, they put the stigma on themselves, that their friends are going to look at them differently, that their friends are going to think, “Oh, maybe they have a contagious disease. Maybe we shouldn't invite them to the swimming pool.”

Dr. Galimberti: And the swimming pool is always a big issue for psoriasis, but I'm going to go a little bit further with that. We talk about the hands. We talk about the scalp, but as the patients grow in age, and they be become a little bit more adult, psoriasis in the private areas become even more important.

Dr. Galimberti: Genital psoriasis is something that it even leads to lower quality of life, and even more sensation of stigma. These patients do not want to have sexual intercourse with their partners, or they stop seeking out for partners because they're embarrassed or because they feel that they're going to be judged because of that rash. And that definitely lowers the quality of their life.

Jennifer: And what about someone who then goes on to develop psoriatic arthritis, where maybe the pain, you can see visibly at times, people will have lesions, and sometimes they look quite painful and they are. But what about somebody where it's impacting their joints on top of that? Does that also impact quality of life?

Dr. Galimberti: Absolutely. And the problem with psoriatic arthritis is that sometimes, patients don't tend to question whether they have a rash or not. They see the rash, they seek for attention, but sometimes it's easier to think, “Oh, getting a little bit older. Oh, my shoulder is not what it used to be. My knees are not as strong as they used to be.”

Dr. Galimberti: So for these patients, they have less quality of life, because they're a little bit in pain. They don't want to go out for a walk with their significant other. They don't want to walk the dog, but at the same time, they might not bring that up to their dermatologist. They might not have a rheumatologist, because they're being treated for psoriasis only for their skin.

Dr. Galimberti: So it's important for both the patients and the physicians to take a deep breath, and let's talk about a little bit beyond the skin. Let's talk about how do you feel about your psoriasis? Not just how does your psoriasis look, but how does your psoriasis make you feel?

Jennifer: Yeah, because depression and anxiety can be huge factors in all of this. I know one of the episodes, we've talked about catastrophizing. We were talking about the concept of catastrophizing from the atopic dermatitis perspective, but I think that that can apply to many different skin issues, and can also make you feel even worse and more traumatized and more depressed. So do you see a connection with your patients between psoriasis and depression?

Dr. Galimberti: So I see with my patients, but more importantly, they're seen worldwide. So that's something that has been very well-documented over the years. Patient with psoriasis, independent of the severity of the psoriasis, have an increased risk of depression, anxiety, and even other psychiatric comorbidities. So these patients, not necessarily just because of their skin, but partly because of the decreased quality of life, they have this sensation of feeling worthless or feeling not up to part.

Dr. Galimberti: And that catastrophizes the situation, incentivizes a bad circle that just keeps putting them in a deeper spiral. And eventually, that might even lead them to stop seeking for medical attention, if not even suicidal ideation, the thought of hurting themselves.

Jennifer: Oh my goodness. I think a lot of people go, “Well, that that's just a mental thing,” right? Is there some physical possibly, or chemical connection, so to speak, between having psoriasis and then going on to develop say, something like depression?

Dr. Galimberti: So to me, this is probably one of the most fascinating points of science right now, the human sciences right now, because as time passes, we begin to understand more and more that our sensation, as well as the way that we feel, the way that we think about the world are influenced by inflammation as well.

Dr. Galimberti: And psoriasis, it's an inflammatory condition. So one of the things that really got me motivated to become involved into this field of psoriasis and psychiatric comorbidity was the fact that we now know that patients with depression, severe depression in particular, have elevated level of a molecule called interleukin 17.

Dr. Galimberti: Now, this molecule is very important because it's classically targeting psoriasis with some of the injectable. So we know that it's important in psoriasis. It can be targeted in psoriasis for treatment, but we now also know that it's important for patients in depression as well.

Dr. Galimberti: It's not being targeted in depression yet, but we do know that it's elevated in these patients. And then there's something else that blew my mind. Let's take a mouse, we're doing an animal study. We inject this mouse with IL-17, which is the same interleukin that we know it's important in psoriasis. And what happens to the mouse? The mouse starts acting like a sick mouse, a depressed mouse.

Dr. Galimberti: There's less movement. There's less seeking for food. There's less seeking for a sexual gratification. So these mice become prone to psoriasis. They have the same or similar inflammatory milieu as a psoriasis patient, but at the same time, they show behavior of a depressed patient. So now, we have the connection, the molecular connection between psoriasis and depression.

Jennifer: So does the interleukin 17 or IL-17, sometimes people will see it written both ways on the internet or in texts, does it potentially create inflammation within the brain?

Dr. Galimberti: So interleukin 17 or IL-17 is very important for inflammation, it's very important for psoriasis. It's something that it's part of our body, but of course, it's deregulated or is different level of expression in psoriasis, as well as these conditions.

Dr. Galimberti: Now, the brain is a little bit more difficult to study. There's a broad brain barrier. So it's a little bit difficult, and those studies, of course, we don't want to do biopsies on the brain. We do have MRIs, so you can see inflammation, but other organs besides the skin, they're a little bit easier to target and to study with simple study, even for example, the heart, where we have very easy imaging for the heart, you do see inflammation in the heart of patients with psoriasis.

Dr. Galimberti: So we do know that the inflammation with psoriasis, it's not just in the skin. It's not just perhaps in the joints, but it's all over the body. It can be in your GI system. Think about the situation with psoriasis and inflammatory bowel disease. It can be in your heart, and perhaps, that's similar with inflammation. It's what's causing or leading or predisposing to depression.

Jennifer: So I want to help somebody who's listening to this going, “Oh my gosh, I'm doomed,” because I think that someone could think that. You could have someone on one hand say, “Wow, this explains so much.” And then on the other hand, someone's like, “See, I'm just doomed. Forget about it. I'm just going to give up. If this is infiltrating my system, then I can't win.”

Jennifer: And so, I do want to stress that there are ways to help support someone. So I don't want anyone to walk away from this conversation feeling doomed.

Dr. Galimberti: Absolutely, quite the opposite. I think this is actually an empowering moment. Why do I think it's empowering? I think it's empowering because first of all, if you're a psoriasis patient and you feel depressed, it's not that you feel depressed. It's not something that you did. It's not something that you're bringing to yourself. There is actually a mechanism, it's happening. You're not just feeling that. You're not just thinking about that.

Dr. Galimberti: Additionally, if we understand the mechanism, we can target it. We have mechanisms. We have things that we can use to target those mechanisms in psoriasis. And more importantly, as more physicians and more patients become aware of the connection between psoriasis and psychiatric comorbidities, whether it's depression, anxiety, that's when more physicians from different specialties will come together to help those patients.

Dr. Galimberti: So if you're a patient in need, in reality, there's nothing better to actually understand that we are getting to the point where we understand what's going on so we can better serve you as physicians, and we can better serve you not as a patient, but as a human being, as a wholesome, as an entire person.

Jennifer: Dr. Galimberti, I think that's so important. But so you as a dermatologist, you can only do so much. Obviously, you can be there to help support someone from a mental health perspective. Do you think that also too, it underscores perhaps the importance if you are feeling depressed or anxious to seek out some sort of mental health support, whether it's through a licensed therapist, or some sort of talk therapy that could be beneficial to somebody who's really struggling with quality of life or depression?

Dr. Galimberti: Absolutely. That is incredibly important. And as a physician, my opinion is not only that you as a patient should seek comfort. I think us physician from different specialties should come together and offer the deal of interdisciplinary clinics. These are clinics where a dermatologist can help you with your psoriasis, but at the same time, a licensed physician who's good, who knows how to handle the anxiety, depression can help you. I want to help you, but I'm not trained in that.

Jennifer: True.

Dr. Galimberti: I can only give you my opinion, but if the same physicians can be in the same room or next to each other, then those visits to me will be even more important. And I think eventually, we'll start thinking of inflammatory condition as systemic condition that don't just go to the skin. So these interdisciplinary clinics will become more popular. They already exist. They're typically employed for rheumatoid arthritis, for some of the rheumatologic conditions, but I think sooner or later, hopefully sooner than later, we'll be able to provide that for our patients with psoriasis or with atopic dermatitis.

Jennifer: And quality of life too, and also your mindset and outlook on things will determine how compliant. I found that with my practice. If someone really feels like they're doomed, they're likely not going to take steps that are recommended to them.

Jennifer: They're less likely to be compliant, to show up on time, to do whatever it is that they need to do to care for themselves, because they're like, “I just don't see the point.”

Dr. Galimberti: It's an excellent point. Indeed, I completely support your point. And I agree with you and you have the hands-on experience, and I have the hands-on experience, but there's so many well-designed studies that shows that the mental health status of the patient impacts the patient/doctor relationship.

Dr. Galimberti: And we now know in 2021, we know that their relationship is incredibly important for the success of the patient. The more clear, the stronger the relation is between the patient and the doctor, the more likely both will be happy. What I mean by that, the patient is going to do better. The physicians are also very happy when the patient does well. So that's a win-win situation. Clearly, it's not easy in those limited amount of time that we have for visit, to set up that environment. But the idea is that medicine is becoming a collaborative effort.

Dr. Galimberti: And I don't mean a collaboration between the physicians that I mentioned earlier, but the patient himself is part of the care team, and I think this, independent of the mental health status, where the patient has anxiety, depression, this will really help improve that. But at the same time, it's very important for me as a dermatologist to think about the mental health status of the patient, because I probably need to change how I approach a patient based on that. If the patient is anxious or depressed, I should talk to them in slightly different ways.

Dr. Galimberti: I should try to perhaps approach those points in different ways, than I will do for a patient who doesn't have anxiety or is not depressed.

Jennifer: I appreciate that about you. The one thing that I loved, and I thought that was so fascinating about your talk from the Integrative Dermatology Symposium was that you had mentioned about it was a discussion on being able to go outside and exercise. And because of COVID, we have this interesting worldwide situation that would've never happened otherwise for that, where everyone for the most part, was locked inside.

Jennifer: Do you want to talk a little bit about what you found in terms of the benefits of being active and getting outside in terms of folks who have psoriasis?

Dr. Galimberti: Absolutely. As you mentioned in the beginning of our conversation today, I live in Miami, which is a place where it's very easy for us to tell our patients, “Listen, go out and get a little bit of sun. Not too much, because too much sun will increase your risk of skin cancer. But a little bit of sun does provide you vitamin D.” Indeed, when you have psoriasis, sun therapy, whether it will be through a phototherapy booth if available, or even helio therapy through the sun is something that has been used for centuries, not millennia, to improve the skin of psoriasis patients.

Dr. Galimberti: Now we live in an interesting time. Things have changed and are still going to change with COVID. And what's clear is that when a group interviewed patients with psoriasis, patients with psoriasis started going out less because of COVID. They couldn't exercise because of COVID. Not only their psoriasis got worse, but the quality of life gets significantly worse than patients without psoriasis.

Dr. Galimberti: So everybody's quality of life got worse during the lockdown, during the isolation time. But patients who have inflammatory conditions like psoriasis, they experience a even more severe, profound worsening of the quality of life. So if you can, I do advise you to be involved with exercise. Socialize. Now, clearly there might be some limitation in how you feel about doing that. And that's when me and other providers can come in and provide you with some support.

Dr. Galimberti: But at the same time, one thing that I do want to emphasize, which I think it's very important for patients with psoriasis, is the idea of support groups, talk to other patients who have psoriasis, whether you want to do it on Facebook, whether you want to do it on Instagram, whether you have another mass media or social media way of communicating. Think about the fact that especially with psoriasis, you are not the only one with psoriasis, at least three to 4% of the population in the US has psoriasis. That's a very large percentage.

Dr. Galimberti: So go seek for help, seek for support. There's nothing more important than to know that somebody next to you had the same problem, and they were able to solve it. And that's independent of their interleukin 17, of the TNF alpha. If that experience that somebody can share with you, they will probably give you a little bit of more of a spark to not only seek treatment, but follow the treatment.

Jennifer: And what are some of the treatments that you've explored in terms of maybe more on the complementary or alternative side to support your psoriasis patients?

Dr. Galimberti: So there's phenomenal medications nowadays for psoriasis. They don't necessarily work for everyone. Some people might not be candidate for them. Some people might not want to take it, but there are little interesting lifestyle modifications that can make a big difference in psoriasis.

Dr. Galimberti: And some of them are actually somewhat fun, so anybody should think about those. For example, musical therapy. Musical therapy have been shown in multiple studies to help improve the skin clearance in psoriasis. Now, interestingly enough, it works even better when used in combination with other therapy. For example, patients that are being treated with phototherapy, they go and they sit in front of these specialized for psoriasis, their skin gets clear faster if they're listening to relaxing music while being exposed to the light.

Dr. Galimberti: Now, this is of course a very complicated concept that perhaps at this point in time, we don't fully understand the interleukins. We don't fully understand the little molecules that are changing, but there's real life evidence of that. And that's what I love about this. I think these things are a little bit too complicated for us, it'll be too simplistic to say it's only because of this, it's only because of that.

Dr. Galimberti: But certainly, it's working. And so that's something that we can do. I share another one with you, which I think is really fun, but that's a little bit more complicated, and that's idea of a climate therapy or climatotherapy. Now that's something that we need to date back and think back, how do people before biologics or before modern medicine treated psoriasis? Now, as you can probably guess from my accent, I'm Italian, and we have a long history of medicine in ancient Europe and ancient Rome, ancient Greek.

Dr. Galimberti: So how did they treat psoriasis when modern medicine wasn't available? Well, back in those days, they knew that going by the ocean, going to areas that have thermal baths could help and modern medicine, these are good studies in modern medicine, have only replicated those data. It's not help you as much as modern medicine, but it might give you an edge or it might make your mild psoriasis into something that doesn't bother you anymore, or it might make your severe psoriasis something that can be controlled along with a biologic.

Jennifer: And you know what's interesting? I've had multiple clients tell me that when they went on vacation to the beach, and they went in the water, and they were out in the sun, their psoriasis got significantly better. And granted, there's the sunshine factor.

Jennifer: So there's that, but I've even had clients, this is slightly different, but I've had clients with atopic dermatitis or eczema also say the same thing. Do you have any idea why salt water, and these natural… even the thermal springs, is there any research at all to possibly explain why?

Dr. Galimberti: It's a very complicated subject, because there's a lot of variables out there. Now the first thing that I want to point out is that not only patients who go vacation in those areas though, any sort of relaxation, which doesn't have to be in a vacation, you could learn how to relax at home. Yoga, all those things that can make you more relaxed, more acceptive of your life, and better understanding of your life, a better understanding of yourself as well can help psoriasis.

Dr. Galimberti: So that plays a role with the vacation. However, when they did studies, particularly this was in the Dead Sea, they notice that the bacteria on the skin before and after in the time in the season during these vacation changes. And we now know that the number and types of bacteria that live on your skin is different when you have psoriasis, when you have mild psoriasis and when you have the flare of psoriasis.

Dr. Galimberti: So that's really important. So perhaps, that's one of the many mechanisms, but I think that's going to play an important role. And what we actually are seeing in modern medicine is that the idea of our interaction with the bacteria, not just with the bad one, but also with the good ones, that are always on our skin, it's very important. And perhaps, reestablishing some equilibrium on the bacteria on your skin can help psoriasis and maybe can help atopic dermatitis or eczema, as you mentioned.

Dr. Galimberti: So lot of things at play. And I think when it comes to complimentary alternative medicine, it's important to think about it as many things coming to play into once. And we really shouldn't try to oversimplify this by saying, “It's because of this.” But that's part of a very, very big mechanism, that overall leads to improvement.

Jennifer: I love that. I love that. I'm so glad that I had the opportunity to see your talk and that we were connected, so that you could come on the show and talk about this. I really appreciate it, because one of my goals this year with the show is to make sure to start talking about the trauma and mental health, and how we can integrate in things like mindfulness-based stress reduction practices, and all sorts of things to help support people better from that whole person picture.

Jennifer: And so I really appreciate you being here today. Thank you so much for sharing this. I know that you do see patients, you actively see patients in Miami. Which hospital do you work through?

Dr. Galimberti: The university of Miami.

Jennifer: Okay. And we'll put your link, if anyone wants to get in touch with you. We'll put your link and information in the show notes, that way, it's very easy for all of those out there, those people out there who are struggling with psoriasis or eczema, if this really resonates with them, they can get in touch with you, and perhaps become your patient.

Dr. Galimberti: It was a pleasure chatting with you. So many things that I want to talk to you about with a limited amount of time, but absolutely a pleasure. And thank you so much for having this podcast for all the patients that listen to you.

Genital psoriasis is something that it even leads to lower quality of life, and even more sensation of stigma. These patients do not want to have sexual intercourse with their partners, or they stop seeking out for partners because they're embarrassed or because they feel that they're going to be judged because of that rash.