While the use of nonpharmacologic interventions may seem counterintuitive, these therapies have been shown to improve psychosocial function and reduce the negative emotional states that can exacerbate or even elicit skin disease, said Dr. Fried of Yardley (Pa.) Dermatology Associates. Dr. Fried detailed several strategies and options for managing the mental aspect of skin disorders in an article in the June issue of Seminars in Cutaneous Medicine and Surgery.
"Clinical studies have demonstrated that psychological stress disrupts skin barrier function and increases the severity of cutaneous infections, and down-regulates antimicrobial peptide expression, resulting in more severe skin infections in mice," Dr. Fried wrote.
"This self-perpetuating negative interaction between stress and impaired skin function has been well-described and often underlies the so-called ‘vicious cycle’ that exists between skin and negative emotional states," he said.
Dr. Fried proposed three broad categories of ‘psychocutaneous’ patients. First, there are individuals with skin manifestations associated a psychiatric diagnosis such as depression, anxiety, or body dysmorphic disorder.
The second category includes patients with psych-derm conditions such as acne excoriée, neurotic excoriations, dermatitis artefacta, and trichotillomania. The third category covers patients with common skin conditions such as acne, rosacea, psoriasis, eczema, and urticaria that are known to be impacted by emotional factors.
Dr. Fried suggested that even patients dealing with the dermatologic effects of aging may be at risk for negative emotional sequelae and may benefit from nonpharmacologic interventions.
Hypnosis is one intervention that has been shown to benefit some patients. For example, long-lasting effects of hypnosis (particularly in highly hypnotizable patients) may include reduced scratching in eczema, and can aid resolution of acne excoriée.
"Recent studies in patients with alopecia areata (including several with ophiasis distribution) demonstrated that hypnosis promotes excellent regrowth in approximately 50% of treated patients and improvements in depression and anxiety in almost all patients," Dr. Fried reported.
Cognitive-behavioral psychotherapy is one of several common psychotherapy interventions used to treat the psychological aspects of skin disorders. Data from a 6-week study of cognitive-behavioral therapy in psoriasis patients showed improvements in anxiety, depression, and psoriasis-related stress, compared with patients who didn’t receive the therapy. In addition, the psychotherapy intervention group showed three times the clinical improvement, compared those undergoing conventional treatment without therapy.
Group psychotherapy has also been associated with symptom reduction, decreased pruritus, fewer eczema relapses, and decreased steroid use in patients with eczema who used it to supplement to their regular medication.
But nonpharmacologic interventions can also be practiced in a less formal manner by dermatologists themselves, Dr. Fried said.
"The power to heal by words, manner, and touch cannot be overstated. Gentle, compassionate, and optimistic comments and gestures can affect the physiology, emotional well-being, and compliance of our patients," he said.
Dr. Fried said referral to a psychodermatologist or mental health professional with an interest in dermatologic manifestations may help some patients, but sometimes treatment can be as simple as a patient’s regular dermatologist offering reassuring words to, "assuage some of the ‘terror of chronicity and progression’ that haunts our patients," he said.
Dr. Fried stated that he has received compensation for the development of educational papers from Ranbaxy, Bayer, Valeant, and Promius.