White paper on psychodermatology in Europe: A position paper from the EADV Psychodermatology Task Force and the European Society for Dermatology and Psychiatry (ESDaP)

From Itch to Access: Psychodermatological Care Challenges and the Promise of Telehealth

Background/Objectives: Pruritus is a prominent symptom of chronic inflammatory skin diseases and significantly affects quality of life. Psychological stress can exacerbate pruritus and worsen skin conditions, yet psychological aspects are often insufficiently addressed in clinical routine. While psychodermatological treatments are becoming more available in German-speaking countries, they are mostly confined to specialized clinics, limiting access for many patients. This study aims to explore the unmet needs of patients with chronic inflammatory skin diseases in German-speaking regions and assess the potential role of telemedicine in bridging existing psychodermatological care gaps. Methods: Patients with chronic inflammatory skin diseases were invited via the Network of People with Autoimmune Diseases to participate in free video consultations with a licensed psychotherapist. Quantitative data on disease, pruritus, and distress were analyzed alongside qualitative feedback from consultations and surveys. Results: Of 174 individuals who received the newsletter, 124 opened it, and 16 engaged with the scheduling link. Over one month, five patients (mean age 40.4 years, all female) participated in psychodermatological video consultations. All had chronic inflammatory skin diseases and were under dermatological care but felt insufficiently treated by dermatological approaches alone. Barriers to multimodal care included lack of awareness, distance to specialized clinics, and long waiting times. Three participants reported pruritus with an average intensity of 75/100 on a Visual Analog Scale (VAS). Psychological factors were identified as significant contributors to pruritus by all participants. Post-consultation, 4/5 of participants completed a survey, reporting high levels of distress (average 74/100 VAS) and favoring online or hybrid treatment options. Conclusions: Dermatological treatment alone often fails to address psychological aspects in patients with chronic inflammatory skin diseases. These findings emphasize the need for integrated dermatological and psychological treatment, with telemedicine offering a valuable avenue to improve access and foster interdisciplinary collaboration.

Immune links in comorbid depression and psoriasis: A narrative mini-review and perspective

Evidence suggests a bidirectional association between psoriasis and depression, which is considered to reflect complex neuroimmunological and psychosocial interactions. Despite an early interest in the brain-skin axis and the role of stress in psoriasis immunopathogenesis, there is ongoing limited preclinical and clinical research into the inflammatory links between depression and psoriasis. Existing findings for serum inflammatory markers of depression in psoriasis are inconsistent and do not fully align with those in the general population, while brain imaging evidence is scarce and has not confirmed direct brain involvement in the systemic inflammation of psoriasis. The present paper reviews the available literature on the immune interplay of psoriasis with depression, highlights the significance of further work in the field and proposes avenues for future research.

[Comprehensive training in psychodermatology: the diploma course of the European Society for Dermatology and Psychiatry]

BACKGROUND

Psychodermatological conditions play an important role in dermatological practice. The biopsychosocial disease model is of central significance.

OBJECTIVE

Psychodermatological knowledge is underrepresented in specialist training and medical care. There is a need for continuing education offers for primary psychodermatological disorders as well as for skin diseases related to psychological stress.

MATERIALS AND METHODS

The work comprises a description of the structure, organization, and content of the diploma course offered by the European Society for Dermatology and Psychiatry (ESDaP), along with a personal conclusion after completing the course.

RESULTS

Continuing education in the diagnosis and treatment of psychodermatological disorders should be an integral part of dermatology training. The ESDaP diploma course conveys knowledge regarding psychosomatic dermatology and dermatopsychiatry. The target audience includes dermatologists, psychologists, psychiatrists, and psychotherapists in training and practice. The two-level course offers foundational knowledge for those working with psychodermatological patients in level 1, while level 2 allows for advanced specialization. Additional requirements for obtaining the diploma include case presentations, lectures, and multiple-choice examinations.

CONCLUSION

Psychological factors are common in dermatological patients and require effective and holistic management. The ESDaP diploma course provides in-depth knowledge and fosters skills in patient care and physician-patient communication.

A qualitative exploration of the prospective acceptability of the MiDerm app; a complex digital intervention for adults living with skin conditions

OBJECTIVES

Skin conditions carry a substantial psychological burden but support for patients is limited. Digital technology could support patient self-management; we found preliminary evidence for the effectiveness and acceptability of digital psychological interventions for adults living with skin conditions. We have, therefore, developed a complex digital intervention called MiDerm with patients. This qualitative study explored the prospective acceptability of the complex intervention delivered via a smartphone application (app), and possible barriers and facilitators to use.

DESIGN

Qualitative research involving a hybrid inductive-deductive approach. Data collection and analysis were theoretically informed by The Common-Sense Model of Self-Regulation, Theoretical Framework of Acceptability and the Capability, Opportunity, Motivation - Behaviour Model.

METHODS

Eight synchronous online group interviews with 43 English-speaking adults (≥ 18 years) with skin conditions. Data were analysed using Reflexive Thematic Analysis.

RESULTS

Three superordinate themes were generated: (1) Patients' attitudes and concerns about the MiDerm app; (2) Need for personal competence, autonomy and relatedness for effective self-management; and (3) Physical, psychological and social barriers to app use.

CONCLUSION

Adults with skin conditions, mainly those with vitiligo and psoriasis living in the UK, expressed the need for support to self-manage the psychological aspects of their condition(s). The idea of a new intervention comprised of informational, emotional, behavioural and peer support, delivered via a smartphone app was welcomed and may be especially beneficial for specific patients. Identified barriers must be addressed to maximize engagement and giving users choice, flexibility and control is imperative to this. We have since developed the MiDerm app using these findings.

Psychodermatology in Hungary: Awareness and practice patterns of dermatologists

Background

Psychodermatology is an interdisciplinary branch of medicine between psychiatry /psychology and dermatology.

Objectives

This study aimed to assess Hungarian dermatologists' awareness, practice patterns and attitudes towards psychodermatology.

Methods

A questionnaire-based survey was sent from October 2020 to June 2021 to 100 dermatologists (including residents in dermatology) in Hungary with a response rate of 51%. The participants were asked about understanding of the concept of psychodermatology and their training in this field, comfort in treatment, and interest in continuing medical education on dermatological disorders with psychological components.

Results

49% of the respondents understood psychodermatology as a bidirectional interaction of the patient's mental and dermatological conditions, and 25.5% were comfortable in treating psychodermatological patients. The most common dermatological diagnoses with psychological/psychiatric involvement reported were psoriasis and atopic dermatitis. Atopic dermatitis, anxiety, delusional parasitosis, and depression were the most common diagnoses when dermatologists referred patients to psychiatrists. In total, 76.5% of participants could not name any resource (magazine, website, etc.) for patients and their families where information about psychodermatology is available, and 58.8% showed a definite interest in attending training on psychodermatology.

Conclusion

The results of our study suggest that Hungarian dermatologists have a high awareness of the term "psychodermatology", and only a quarter of practitioners feel adequately equipped and comfortable managing patients with psychosomatic aspects in their treatment. The relatively large gap between the number of patients with a psychodermatological component and referrals by dermatologists to mental health specialists indicates the potential importance of more intensive collaboration between dermatologists, psychiatrists and/or psychologists.

Integrative Treatment Approaches with Mind-Body Therapies in the Management of Atopic Dermatitis

Atopic dermatitis (AD) is a chronic inflammatory skin disease with a complex pathophysiology characterized by intense pruritus, often associated with psychological stress and atopic and non-atopic comorbidities that significantly reduce quality of life. The psychological aspects of AD and the interaction between the mind and body via the skin-brain axis have led to an interest in mind-body therapies (MBT). The aim of this article is, therefore, to reinforce the importance of psychodermatological care in AD. We performed a focused literature review on holistic practices or integrative MBT in AD, including education, cognitive behavioral therapy, habit reversal, meditation, mindfulness, hypnotherapy, eye movement desensitization and reprocessing, biofeedback, progressive muscle relaxation, autonomous sensory meridian response, music therapy, massage, and touch therapy. A multidisciplinary holistic approach with MBT, in addition to conventional pharmacologic antipruritic therapies, to break the itch-scratch cycle may improve AD outcomes and psychological well-being. Although there is a paucity of rigorously designed trials, evidence shows the potential benefits of an integrative approach on pruritus, pain, psychological stress, anxiety, depressive symptoms, and sleep quality. Relaxation and various behavioral interventions, such as habit reversal therapy for replacing harmful scratching with massaging with emollient 'plus', may reduce the urge to scratch, while education may improve adherence to conventional therapies.

Unmet Needs in Psychodermatology: A Narrative Review

Psychodermatology, the multidisciplinary field that explores the intricate interplay between the mind and the skin, has gained increasing recognition over the past decade. However, several knowledge gaps and unmet needs persist in the field. The objective of this narrative review was to investigate the unmet needs in the field of psychodermatology as they pertain to medical training, treatment, research, and care access. PubMed was searched from inception through December 2023 to identify articles related to psychodermatology. Findings revealed several unmet needs within the field of psychodermatology. First, there is a need for further investigation into the pathophysiology that links psychological stress to cutaneous disease including the development of novel therapies targeting key neuropeptides. Second, the existing literature focuses primarily on the pharmacologic treatment of body dysmorphic disorder and body-focused repetitive behaviors, as well as delusional parasitosis, for which the first-line agents are selective serotonin reuptake inhibitors and atypical antipsychotics, respectively. However, additional research into the efficacy and safety of the remaining psychotropic medications and the treatment of other common psychocutaneous diseases is required. Finally, there exists a significant gap in knowledge amongst clinicians tasked with treating psychocutaneous diseases. Dermatologists report low rates of training in psychodermatology and discomfort with prescribing psychotropic medications. In conclusion, increasing resources for dermatologist education on psychotropic agent use, development of new drugs targeting stress-induced skin conditions, and research on the psychocutaneous applications of current medications may greatly improve the quality and access of psychodermatology care.

The skin-brain connection and pleasant touch as supportive care for psychocutaneous disorders

Psychodermatology is a subdiscipline of dermatology at the intersection of dermatology, psychiatry, and psychology. In dermatology clinical practice, patients may present with skin disease that affects their mental health, or skin disorders induced or worsened by psychological/psychiatric problems so there is a need for specialised education of dermatologists, as well as multidisciplinary teams, to achieve better management of these patients. Understanding the interaction between the central nervous system and the skin underlying psychocutaneous disorders could help identify alternative therapies that may improve patient well-being. The concept of pleasurable touch has received increasing attention following the discovery of C-tactile (CT) fibres. While afferent C-fibre stimulation is usually associated with pain, temperature, or itch, CT-fibres are stimulated optimally by a stimulus not in the nociceptor range but by a gentle, low-force stroking. As this affective touch may counteract unpleasurable sensations, such as pain and itch, and elicit positive feelings, the potential benefits of gentle touch and massage are interesting for dermatological, especially psychocutaneous, disorders. Here we provide an overview of the skin-brain connection to help understand the benefits of touch and massage, as illustrated with studies on atopic dermatitis and burns, as an adjunct to dermatological treatment for improving patient well-being and optimising treatment outcomes.

Risk of developing psychiatric disease among adult patients with skin disease: A 9-year national register follow-up study in Norway

Background

The existing association between skin disease and psychiatric comorbidity has gained attention during the last decades. Stress and mental illness can directly or indirectly affect skin disease, while dermatological conditions, known to impair life quality and mental well-being, can promote psychiatric conditions.

Objectives

The aim of this study was to assess the risk of developing psychiatric disease among adult dermatological patients over a period of time. The secondary objective was to see which psychiatric disorders developed most commonly, and which skin diseases posed the greatest risk for later mental health issues.

Methods

Adult dermatological patients were followed for 9 years (2008-2016) using the Norwegian Patient Registry, for both outpatient and inpatient specialist healthcare services. Dermatological patients were identified during the first 2 years and were then followed for psychiatric comorbidity prospectively for the next 7 years.Cox regression models were applied to estimate the risks of psychiatric disorders among patients with skin diseases. Estimates were adjusted for age and gender differences. Hazard risk ratios (HR) with 95% CI are reported.

Results

Dermatological patients developed depressive disorders most frequently (4.1% vs. 2.3% in non-dermatological participants), followed by anxiety disorders (3.3% vs. 1.8%), and adjustment disorders (2.6% vs. 1.5%). Developing depressive disorders showed the highest HR among dermatological patients, HR (95% CI) = 2.5 (2.4-2.5), followed by disorders related to alcohol use, HR (95% CI) = 2.2 (2.1-2.5), and anxiety disorders, HR (95% CI) = 2.1 (2.1-2.2). Papulosquamous disorders were the skin conditions with the highest HR for developing a mental health condition, with depressive disorder having HR (95% CI) = 2.6 (2.5-2.9); anxiety disorders at HR (95% CI) = 2.9 (2.7-3.1); and disorders related to alcohol use at HR (95% CI) = 3.2 (2.8-3.6).

Conclusions

The study demonstrates that having a skin disease doubles to triples the risk of developing a psychiatric illness within 7 years, especially depression, anxiety, and alcohol use compared with the general population.