Stellate ganglion block achieves remission of recurrent head-and-neck plaque psoriasis: A case report

Abstract

Psoriasis is a chronic immune-mediated inflammatory disease, and recurrent lesions involving the head and neck can be particularly difficult to manage in clinical practice. Herein, we report a case of recurrent head-and-neck plaque psoriasis treated with stellate ganglion block, an autonomic neuromodulatory intervention. A woman in her 40s had a 6-year history of relapsing plaque psoriasis despite treatment with topical calcipotriol and targeted narrowband ultraviolet-B (UV-B) phototherapy. She declined biologic therapy because of safety concerns. She presented with new erythematous, pruritic plaques on the scalp and neck. Physical examination showed well-defined erythematous, scaly plaques on the forehead, retroauricular regions, and neck. Ultrasound-guided stellate ganglion block was performed with 5 mL of 1% lidocaine, injected alternately into the left and right stellate ganglia once daily for 6 consecutive days. Based on the initial response, a second course was administered, and all other psoriasis treatments were discontinued. Pruritus improved substantially within 48 h of treatment initiation, followed by progressive resolution of erythema and scaling. Complete clearance of the lesions was achieved after two courses of stellate ganglion block. No adverse events were observed, and the patient remained in stable remission during 3 months of follow-up. Although limited to a single case, this observation suggests that stellate ganglion block represents a potential adjunctive therapeutic strategy for patients with recurrent head-and-neck plaque psoriasis. Further studies are warranted to define its efficacy, safety, and mechanistic basis.

Introduction

Psoriasis is a common chronic papulosquamous skin disease affecting individuals of all ages worldwide. ¹ Currently, it is widely recognized as a systemic immune-mediated inflammatory disorder rather than a condition confined solely to the skin. ² Plaque psoriasis is the most prevalent clinical subtype, accounting for more than 80% of all psoriasis cases. ³ Although a range of treatment options are available, including topical agents, phototherapy, conventional systemic therapies, and biologics targeting specific cytokine pathways, long-term disease control remains difficult in some patients because of limited efficacy, adverse effects, contraindications, or financial burden. ⁴ These limitations underscore the need for adjunctive or alternative therapeutic approaches that act through novel mechanisms to restore immune balance.

Stellate ganglion block (SGB) is a minimally invasive autonomic modulation technique with rapid, reproducible therapeutic effects and a favorable safety profile. It has been successfully used in various clinical settings.^5–9 By reducing sympathetic outflow, SGB is increasingly recognized for its capacity to suppress both systemic and local inflammatory responses,^10–12 which are central to the pathophysiology of psoriasis and may contribute to disease exacerbation. These mechanistic considerations suggest that SGB may have therapeutic potential in psoriasis; however, clinical evidence remains limited. Herein, we present a case of mild plaque psoriasis refractory to conventional therapy that achieved rapid and sustained remission following ultrasound-guided SGB. Moreover, we discuss the possible links between sympathetic blockade and psoriatic inflammation.

Case description

A woman in her 40s presented with a 6-year history of plaque psoriasis and no known systemic comorbidities. The initial lesions developed on her neck in 2019, manifesting as scattered erythematous plaques with scaling and pruritus. She was diagnosed with psoriasis by dermatologists at another hospital and received topical calcipotriol ointment (LEO Laboratories Ltd., Ireland; 0.75 mg/15 g). Although the lesions showed marked improvement, they did not resolve completely and recurred after discontinuation of treatment.

In January 2025, the patient developed recurrent disease, characterized by new erythematous, pruritic plaques on the scalp and neck. Despite continued use of calcipotriol, the lesions showed no improvement. She subsequently received targeted UV-B phototherapy three times weekly for 2 months, but the lesions persisted. During follow-up, biologic therapy was recommended by her dermatologist; however, she declined this option because of concerns regarding potential adverse effects. Persistent pruritus and the visibility of lesions on the face and neck caused substantial cosmetic distress and anxiety.

When the patient presented to our hospital in August 2025, physical examination demonstrated erythematous, scaly plaques on the forehead, retroauricular region, and neck (Figure 1(a) to (c)). The baseline Psoriasis Area and Severity Index (PASI) score was 2, consistent with mild plaque psoriasis. ¹³ Despite the limited overall lesion burden, involvement of cosmetically sensitive areas resulted in substantial cosmetic distress and anxiety. After comprehensive evaluation and shared decision-making, SGB therapy was initiated, and all other antipsoriatic treatments were discontinued.

Figure 1.

Clinical images of the patient before and after stellate ganglion block (SGB) treatment. (a–c) Before treatment, erythematous, scaly plaques were present on the forehead, postauricular area, and lateral and posterior aspects of the neck, accompanied by pruritus. (d–f) After the first course of SGB, erythema and scaling were markedly reduced, with substantial relief of pruritus. (g–i) At the 3-month follow-up after the second treatment course, the lesions had almost completely resolved, with smooth skin and no evidence of recurrence.

SGB was performed under ultrasound guidance (Figure 2). A total of 5 mL of 1% lidocaine was administered alternately to the left and right stellate ganglia once daily, and one treatment course encompassed 6 consecutive days of treatment. After the first course, erythema had markedly subsided (Figure 1(d) to (f)), and the patient reported rapid and substantial relief of pruritus within 48 h. A second treatment course was then administered. At the 3-month follow-up, the lesions had completely resolved, and the PASI score had decreased from 2 at baseline to 0, indicating complete clinical remission without recurrence (Figure 1(g) to (i)). The patient expressed high satisfaction with the therapeutic outcome, and no complications, including infection or nerve injury, were observed.

Figure 2.

Ultrasound-guided stellate ganglion block (SGB) procedure. The sonographic image is shown alongside an anatomical diagram to facilitate localization of the target structure. White arrowheads indicate the prevertebral fascia, and the yellow star marks the target site for anesthetic injection. SCM: sternocleidomastoid muscle; SG: stellate ganglion; LCM: longus colli muscle; PVF: prevertebral fascia; IJV: internal jugular vein; CCA: common carotid artery; VV: vertebral vein; VA: vertebral artery.

Written informed consent for both treatment and publication was obtained from the patient. This case report was prepared in accordance with the Case Report (CARE) guidelines, ¹⁴ and all patient information has been appropriately de-identified.

Discussion

Psoriasis is recognized as a chronic immune-mediated inflammatory disease driven by complex interactions among innate immune cells, adaptive immune cells, and keratinocytes, which together sustain a self-perpetuating cycle of cutaneous inflammation and recurrent flares. ¹⁵ As observed in the present case, recurrent lesions involving the head and neck are often particularly difficult to control. This may be attributable not only to local environmental triggers but also to the psychologic burden associated with cosmetically exposed areas and stress-related neuroimmune activation. Although topical therapy and phototherapy are commonly used treatment options, the patient continued to experience repeated relapses, and she declined biologic therapy because of concerns regarding long-term safety, highlighting the need for alternative or adjunctive therapeutic strategies.

The pathogenesis of psoriasis is complex and has not yet been fully elucidated; however, dysregulated immune activation, particularly inflammation driven by the adaptive immune system, is widely considered a central mechanism.^16,17 Unlike conventional therapies that directly target inflammatory pathways, SGB may offer a distinct therapeutic approach by modulating autonomic nervous system activity. The autonomic nervous system is closely linked to both innate and adaptive immunity, and disruption of the sympathetic–parasympathetic balance may amplify inflammatory responses and contribute to the persistence and recurrence of chronic immune-mediated diseases. ¹⁸ In particular, excessive sympathetic activation has been associated with neurogenic inflammation, vasoconstriction, and amplification of pruritus. ¹⁹

Accordingly, SGB may exert therapeutic effects by suppressing sympathetic overactivity, attenuating catecholamine-mediated stress signaling, improving local microcirculation, and modulating the neuroendocrine–immune network, thereby helping restore systemic homeostasis. As the stellate ganglion is a key sympathetic relay for the head-and-neck region, SGB has been widely used in the diagnosis and treatment of autonomic dysfunction involving the head, neck, and upper limbs. Previous studies have shown that SGB can improve regional blood flow without significantly affecting overall hemodynamics and may also regulate endocrine and immune responses.^20,21 In addition, emerging evidence suggests that SGB can reduce the levels of multiple inflammatory mediators^22,23 and has shown therapeutic potential in inflammatory skin disorders such as seborrheic dermatitis, rosacea, and atopic dermatitis.^21,24,25 These findings indirectly support the potential applicability of SGB in psoriasis.

In the present case, the patient experienced marked relief of pruritus within 48 h of SGB, followed by gradual resolution of erythema and scaling, with complete lesion clearance after two treatment courses. Notably, these improvements occurred in the absence of any concomitant antipsoriatic therapy, suggesting a direct therapeutic effect of the intervention. However, an alternative explanation is the pharmacological effect of lidocaine itself, which may possess anti-inflammatory and antipruritic properties in addition to its role in sympathetic blockade. Lidocaine has been reported to improve psoriasis by interfering with calcitonin gene–related peptide (CGRP)–mediated neuroimmune signaling, ²⁶ indicating that the clinical response observed here cannot be attributed solely to ganglionic blockade. Nevertheless, the sustained remission after treatment discontinuation and the absence of recurrence during the 3-month follow-up suggest that the benefit may have extended beyond a transient local anesthetic effect and may reflect broader modulation of autonomic and neuroimmune balance.

Nevertheless, findings from a single case cannot establish causality or confirm generalizability. However, the rapid and durable clinical response observed in this patient suggests that SGB may represent a valuable adjunctive treatment option for patients with recurrent head-and-neck psoriasis, particularly those who are unable or unwilling to receive systemic or biologic therapy. Future prospective studies, particularly randomized controlled trials, are needed to determine the optimal treatment regimen, clarify the underlying neuroimmune mechanisms, and identify the patient subgroups most likely to benefit.

Conclusion

SGB may represent a potential adjunctive treatment option for patients with recurrent plaque psoriasis involving the head and neck. Its therapeutic effects may be related to sympathetic inhibition and neuroimmune modulation. Further studies are needed to evaluate its efficacy, safety, and optimal treatment regimen.