Nonpharmacologic management of common skin and psychocutaneous disorders

Stress and Skin: An Overview of Mind Body Therapies as a Treatment Strategy in Dermatology

Stress has multiple and wide-ranging physiologic and clinical impacts on skin disease. This has led to an interest in mind body therapies as potential adjunct treatments for skin disease. The stress response results in the activation of the endocrine, neurologic, and immune systems, with a resulting cascade of impacts, that are both systemic and cutaneous. The 2 main arms of the stress response are the sympathetic nervous system and the hypothalamic-pituitary-adrenal axis. The resultant release of cortisol, catecholamines, and neuropeptides has multiple effects. Clinically, these have been shown to increase skin inflammation, increase itching, impair skin barrier function, impair wound healing, and suppress immunity. Mind body therapies are those that focus on the interaction between the mind and the body, with the goal to influence physical function and impact health. These have been shown to ameliorate some of the harmful physiologic changes attributed to stress or to reduce harmful behaviors. In some cases, such as with biofeedback, they may also result in beneficial physiologic changes. Treatments such as meditation, biofeedback, hypnosis, guided imagery, and others have been evaluated in the treatment of skin disease and have shown some benefits. Although randomized controlled trials are limited, these interventions have shown beneficial effects on itching, psychosocial outcomes, and even skin severity. These interventions have been evaluated in diseases such as atopic dermatitis, psoriasis, trichotillomania, and others. Given the potential benefits, improvements in psychosocial outcomes, and a low risk profile, referral to qualified practitioners or multidisciplinary clinics should be considered for some patients.

Methods to improve quality of life, beyond medicines. Position statement of the European Academy of Dermatology and Venereology Task Force on Quality of Life and Patient Oriented Outcomes

The pharmaceutical approach to skin disease has been hugely successful, but despite effective drugs being available and used, there are still vast numbers of people who continue to have some level of persisting skin disease and continue to experience quality of life (QoL) impairment. So the question that needs to be answered, while we await further advances in our drug-based armamentarium, is how can we improve patients' QoL, beyond drugs? A working group was formed from members of the EADV Task Force on QoL and Patient Oriented Outcomes. Participants were asked to suggest all the ways in which they considered patients' QoL may be improved beyond medicines. Four groups of management approaches that may improve QoL in dermatology were identified: interventions within the dermatology service (hospitalization, multidisciplinary teams, patch testing and establishing relevant allergens and education), external services (corrective make-up, climatotherapy and balneotherapy), psychological (psychological intervention, cognitive therapy, hypnosis), lifestyle (lifestyle behavioural changes, religion and spirituality and music). The ultimate aim of therapy is to eradicate a disease in an individual and return the person's life to normal. But until the day comes when this has been achieved for every skin disease and for every patient there will be a need to support and assist many patients in additional non-pharmaceutical ways. These 'adjuvant' approaches receive too little attention while dermatologists and researchers strive for better pharmacological therapy. The different ways in which patients may benefit have been reviewed in our paper, but the reality is that most have a very poor evidence base. The research challenges that we have to meet are to identify those approaches that might be of value and to provide evidence for their optimal use. In the meantime, clinicians should consider the use of these approaches where QoL remains impaired despite optimal use of standard therapy.

Psychocutaneous disease: Pharmacotherapy and psychotherapy

Building a strong therapeutic alliance with the patient is of utmost importance in the management of psychocutaneous disease. Optimal management of psychocutaneous disease includes both pharmacotherapy and psychotherapy. This article reviews psychotropic medications currently used for psychocutaneous disease, including antidepressants, antipsychotics, mood stabilizers, and anxiolytics, with a discussion of relevant dosing regimens and adverse effects. Pruritus management is addressed. In addition, basic and complex forms of psychotherapy, such as cognitive-behavioral therapy and habit-reversal training, are described.

Psychodermatology: Knowledge, Awareness, Practicing Patterns, and Attitudes of Dermatologists in Turkey

OBJECTIVE

Approximately, 1 in 3 patients in dermatology settings has psychiatric comorbidity. Thus, we conducted a survey in Turkey to explore the awareness, knowledge, practicing patterns, and attitudes of dermatologists toward psychocutaneous disorders.

METHOD

The questionnaire-based study was performed from March 1, 2013, to May 20, 2013. Study participants included 115 dermatologists. The questionnaire consisted of 9 multiple-choice questions and 2 open-ended questions.

RESULTS

Of the 115 dermatologists in the study, 38 were men and 77 were women. More than 85% of dermatologists indicated that they examine > 30 patients per week in their practice, while only 2% saw < 10 patients per week. The most frequent dermatologic condition associated with psychiatric involvement seen by dermatologists was acne (49.1%). The top 3 diagnoses referred by dermatologists to psychiatrists were psoriasis (42.6%), alopecia areata (38.2%), and pruritus (27.8%).

CONCLUSIONS

A need for collaboration between primary care, psychiatry, and dermatology disciplines in handling patients with psychocutaneous conditions is widely accepted. Investigating the knowledge, attitudes, and awareness of dermatologists about psychocutaneous disorders might contribute to the development of new educational strategies and elicit qualified biopsychosocial approaches.

Psychological management of wound pruritus

OBJECTIVE

To explore the psychological treatment options for pruritus in patients with wounds.

METHOD

This study employed a narrative design with a search being completed using the databases Academic Search Complete, Google Scholar, PsycInfo, PsycARTICLES, Medline and CINAHL Plus. All articles between 1980-2013 that included the following search terms: [pruritus OR itch OR itching] AND [management OR psychological interventions OR treatment] AND [wounds OR burns OR wounds burns] were included in the review.

RESULTS

A number of psychological treatments options emerged from the literature search that were suggested to be effective for treating itching. These included methods such as habit reversal, suggestions, relaxation, massage and itch-coping programmes. Each of these methods showed potential for improving the patient experience by reducing itching, although the research evidence is currently somewhat limited.

CONCLUSION

Although itching is a common symptom in wounds, the use of psychological treatments for this may be rather limited. The treatments discussed show promise and their use should be a welcome addition to the healthcare professional's armoury for working with people with wounds.

DECLARATION OF INTEREST

There were no external sources of funding for this study. The authors have no conflicts of interest to declare.

Managing the patient with psychiatric issues in dermatologic practice

Patients often communicate emotions through their bodies and physical symptoms; the skin commonly serves as a means of expression in the patient-doctor relationship. It is important for the dermatologist to be able to indentify psychological issues that manifest in the skin and the interplay between psychiatric and dermatologic conditions. Delusional parasitosis, dermatitis artefacta, trichotillomania, and somatoform disorders all represent dermatologic conditions with underlying emotional causes. Many chronic dermatoses, such as psoriasis, atopic dermatitis, and acne, modulate and are influenced by psychosocial factors. Special issues, including significant medication interactions and the treatment of the "difficult" patient, are reviewed.

Psoriasis, a model of dermatologic psychosomatic disease: psychiatric implications and treatments

Psoriasis is a common dermatologic disorder with psychiatric comorbidity that often goes undetected and untreated. Psoriasis has higher associations with psychiatric illness than do other dermatologic conditions. We conducted a comprehensive qualitative review of all published medical literature on psoriasis and psychiatric comorbidities since 2005. We found that psoriasis patients suffer psychiatric and psychosocial morbidity that is not commensurate with the extent of cutaneous lesions. Biologic therapies and nonpharmacologic psychosocial interventions show promise in treating comorbid psychiatric illness. The main limitations of this review are the low quality of published studies and the infrequent use of basic science endpoints in reporting treatment outcomes. The literature examining the psychiatric comorbidity of psoriasis is expanding but remains of variable quality. Stronger studies will be necessary to more accurately estimate comorbidities and help identify and comprehensively treat suffering patients.

Hypnosis in the treatment of Morgellons disease: a case study

Morgellons Disease is a condition involving painful skin lesions, fibrous growths protruding from the skin, and subcutaneous stinging and burning sensations, along with symptoms of anxiety, depression, fatigue, and memory and attention deficits. The etiological and physiological bases of these symptoms are unclear, making the diagnosis controversial and challenging to treat. There are currently no established treatments for Morgellons Disease. The following case example depicts treatment of a woman with Morgellons Disease using hypnotherapy. Data from this case example suggest that hypnotherapy is a promising intervention for the physical and psychological symptoms associated with Morgellons Disease.