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REVIEW ARTICLE
Year : 2022 | Volume
: 40
| Issue : 2 | Page : 71-77
Psychodermatology: An evolving paradigm
Swapna Bondade1, Abhineetha Hosthota2, R Bindushree2, P Raghul Raj1
1 Department of Psychiatry, The Oxford Medical College, Hospital and Research Center, Bengaluru, Karnataka, India
2 Department of Dermatology, The Oxford Medical College, Hospital and Research Center, Bengaluru, Karnataka, India
Correspondence Address:
Dr. Abhineetha Hosthota
Department of Dermatology, The Oxford Medical College, Hospital and Research Center, Yadavanahalli, Anekal Taluk, Bengaluru, Karnataka
India
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ds.ds_20_22
Psychodermatology is a specialty that highlights admix between psychiatry and dermatology. It is emerging as a new subspecialty in dermatology. The skin and central nervous systems are related through their common embryonic origin – ectoderm. They also have common neuromodulators, peptides, and biochemical systems of internal information. Psychiatry is more focused on the internal invisible symptoms, and dermatology is focused on the external visible signs. This connection between skin disease and psyche has unfortunately been underemphasized. Increased pathophysiological understanding of these issues, with biopsychosocial approaches and clinics of psychodermatology would be highly beneficial. Multicenter research such as prospective case–controlled studies and therapeutic trials about the association of skin and psyche can provide more insight into this unexplored and exciting field of medicine.
Keywords: Disease management, mental disorders, skin diseases, stress
Skin is the largest organ of the body, where there is always a complex interplay between the mind and body which is visible. Brain, nerve, and skin are embryologically derived from the neural plate of the ectoderm. The neuro-immuno-cutaneous-endocrine model was proposed by O'Sullivan et al. to explain the mind and body relationship.[1] It often exhibits as outward signs of stress and turmoil within much like a painting on a canvas, the skin can portray emotions. For example, some people may blush when embarrassed or break out into hives when nervous.[2]
A relationship between psychological factors and skin diseases has long been associated which led to the evolvement of a specialty called psychodermatology. Today, we understand that psychodermatology is a merger between dermatology and psychiatry that deals with the influence of psychosocial stress in exacerbation or chronicity of skin diseases.[3],[4] Synonyms for psychodermatology include psychocutaneous medicine; mind and skin (or skin and mind) medicine; sensoryneuronal dermatology; psycho-somatic dermatology (or medicine); and cutaneous-somatic dermatology (or medicine).[5] Psychodermatology also analyzes existing psychiatric comorbidities in many dermatologic conditions and the role of adjuvant treatment such as psychopharmacological, psychotherapeutic, or social.[6],[7] However, clarifying this definition has not been easy. It would not have been possible without the dedication and effort of many health professionals. In the beginning, there was hardly any knowledge about psychodermatology, in recent times, this discipline has turned into an exciting field of research and support for patients with skin problems.[8] The objective of this review is to concise what is new about the models of care for structuring a psychodermatology practice.
MethodologyAs per the PRISMA guidelines,[9] we searched for studies using the keywords psychodermatology, psychocutaneous, psychosomatic dermatology using websites of MEDLINE, EMBASE, Psyc-INFO, Global Health, PubMed, Biomed-Central, Web of Science, Cochrane Library, World Library- World-Cat, Indian Libraries such as the National Medical Library of India. We identified 690 sources for review from the databases was searched. The articles were excluded due to insufficient information as they were editorials and conference abstracts or without our key search terms. After excluding articles based on search terms, article titles and abstracts, we reviewed 51 full-text articles and included in the review. It is a narrative review, with intent to include recent research and aspects. We did not restrict our data inclusion by any standardized methodology. The differences of opinion among the authors were discussed and resolved by agreement in the review article. Analysis of the articles explicated topics such as history and evolution of psychodermatology, team structure, consultation, and management.
HistoryPsychodermatology has a long history but a short past, which means its history can be traced from the earliest literature related to skin diseases with mental status. However, we cannot refer to psychodermatology as a discipline until the mid-20th century.[10]
Hippocrates related the effects of fear on the skin by that when our heart rate increases, skin sweats. In 1850, Erasmus Wilson wrote a book titled “Diseases of the skin” in the chapter on cutaneous neuroses, he speaks about alopecia areata, hypopigmented lesions, itching, and parasitism mania, now known as delusions of parasitosis. This book is considered by many to be the starting point of psychosomatic dermatology.[11] In 1925, Joseph Klauder observed the importance of psychotherapy in the evolution of skin diseases.[12] Research of Ader in the 1970s, from which originated psychoneuroimmunology, Western medicine began to accept that mind and body are related through chemical substances and cellular receptors.[13] This means that psychodermatology is alluded in the earliest writings; however, rigorous and scientific study did not begin until mid-20th century.[14],[15],[16]
Early stage/anecdotal
The pioneers in this phase were mainly psychiatrists trained in psychoanalysis or dermatologists who cooperated with psychiatrists. At this stage, the concept of specificity arose: the hypothesis that a specific emotional conflict and a personality structure could be related to a certain psychosomatic disease or psychodermatitis.[16]
Methodological phase
In this phase, methodological approach takes into account the scientific contributions of different disciplines to the evaluation of psychodermatological phenomena. At this stage, psychosomatic medicine and psychodermatology were only an adjunct to psychoanalysis.[17] Clinicians trained in dermatology and submitted themselves to psychoanalysis have developed an original psychosomatic approach to skin disease at the Tarnier Hospital (Cochin-Port Royal University Hospital Center). Its main agenda was detection and management of the patient's distress.[18],[19]
Integrative phase
In this phase, the trend toward teamwork was more intense. The large number of disciplines was involved in increasing the awareness of psychological behavior. Here, they considered the evaluation of skin manifestation along with social, familial, and occupational issues underlying the problem as the most important theory for the management of psychodermatological disorders.[18] Once the disorder is diagnosed, management requires a dual approach, addressing both dermatologic and psychological aspects.[8]
Contemporary phase
On May 31, 1987, can be set as starting point for this stage. Michael Musalek, with the invaluable help of Peter Berner and John Cotterill, organized the first International Congresson Psychosomatic Dermatology in Vienna. In this phase, they strongly believed that psychodermatological disorders can be broadly classified into categories such as psychophysiological disorders, primary psychiatric disorders, and secondary psychiatric disorders.[8] This suggests that underlying psychologic conditions can result in cutaneous manifestations, primary cutaneous disorders can lead to psychological distress, and the coexistence of cutaneous disease and psychological conditions can result in exacerbations of both conditions.[20]
PrevalenceThe prevalence of mental disorders in patients with skin diseases is estimated between 30% and 60%.[21] Eighty-five percent of patients with skin conditions reported that psychologic aspects of their skin condition played a significant role in their illness.[5] In the first systematic study of mental disorders among people with skin diseases conducted by Hughes et al., a higher prevalence of mental disorders among dermatological clinic patients than among the general population was observed.[22]
Dermatology participates in this scientific development much more than the other fields of medicine because everything that affects the skin is visible to the patient and to people around him. In addition, these unpleasant cutaneous signs will damage physical appearance and compromises individual's self-image and self-esteem. The researchers also noticed that the prevalence of mental disorders among patients hospitalized for dermatological reasons is higher than among patients from other wards.[23] The drugs used in treating dermatological diseases, for example, steroids and retinoids may also influence mental disorders.[24] Research on quality of life (QoL) and depression in various dermatological diseases is trending in psychodermatology field.[25]
PathogenesisThe complex interrelationship between the mind and skin has been investigated at both molecular and cellular levels extensively. These organs share a complex language of neuropeptides, cytokines, glucocorticoids, and other effecter molecules. It forms the basis for many inflammatory dermatoses that are triggered or exacerbated by psychological factors[1],[26],[27][Figure 1]. Hypothalamic–pituitary axis (HPA) responds to psychological stress with the upregulation of hormones such as corticotrophin-releasing hormone, adrenocorticotropin-releasing hormone, cortisol, and prolactin. Sympathetic nervous system activation leads to elevated catecholamine levels and release of neuropeptides and neuromediators (substance P and calcitonin gene-related peptide). Skin mast cells are an important target of key stress hormones and mediators. Their activation by the before-mentioned mediators leads to immune dysregulation and various skin disorders.[28] Arck et al. suggested that skin is exquisitely well innervated and has its own neuroendocrine system equivalent to HPA axis as a local stress response system, which is tightly linked to systemic neuroendocrine axis.[29] Suarez et al. described in detail the role of psychoneuroimmunology of stress in the pathogenesis of inflammatory, autoimmune, allergic skin disorder.[30]
Figure 1: Flow-chart of pathogenesis of skin disorders due to psychological stress from Yadav et al.[27] CNS-HPA: Central nervous system-hypothalamic–pituitary axis, CRH: Corticotropin releasing hormone, ACTH: Adrenocorticotropin hormone, GC: Glucocorticoids, CRH-R: CRH receptors, CGRP: Cacitonin gene related peptite.Significance of stress and quality of life
Stress generally refers to tension or psychological pressure that occurs in response to internal (e.g., disease and thoughts) or external (e.g., environmental) factors that disrupt homeostasis.[25] Extensive theoretical work and a growing number of empirical studies have implicated stress in the onset, exacerbation, and re-occurrence of signs and symptoms across a wide array of skin diseases.[31] Furthermore, stress and skin disease have been found to inhibit social, occupational, and emotional functioning, resulting in diminished life quality across a wide range of skin diseases.[32] For many years, practitioners and researchers have been aware of how skin diseases affect different aspects of patients' lives and how successful treatment may improve patients' QoL. The creation of the Dermatology Life Quality Index (DLQI) questionnaire by Finlay and Khan.[33] in 1994 facilitated many studies on the impact of skin diseases on patients' QoL. That measure was rapidly used in clinical trials for the assessment of treatment efficacy in parallel with the measures of clinical severity.[34] The DLQI was translated into different languages, and many other dermatology-specific and disease-specific QoL instruments were developed. In the age of “precision medicine,” the consideration of QoL allows a specific focus on a new dimension, the very personal problems and needs of a patient. There has been major progress in the field of QoL studies. QoL in dermatology is most commonly been assessed by means of generic instruments and/or dermatology-specific and disease-specific instruments.[35] Researchers and clinicians, therefore, have a wide choice of instruments to show the disease-specific QOL scales.[36]
Infants' Dermatitis QoL IndexQoL Index for Atopic DermatitisChildhood Atopic Dermatitis Impact ScaleCardiff Acne Disability IndexAcne-specific QoL QuestionnaireSkin Cancer IndexThe Functional Assessment of Cancer Therapy – MelanomaPsoriasis Disability IndexChronic Urticaria QoL Questionnaire. Classification of Psychodermatological DiseasesThere are several types of classification of psychodermatological diseases. Two decades ago, Koo and Lebwohl were the first to categorize psychodermatologic disorders into the following three groups: psychophysiologic (or psychosomatic) disorders, primary psychiatric disorders, and secondary psychiatric disorders.[37] As this classification system indicates, there is a mutual relationship between psychological symptoms and skin disease. Treating skin condition can often reduce mental stress and negative feelings associated with symptoms. Similarly, treating comorbid psychiatric diseases such as depression or obsessive–compulsive disorder will consequently improve skin condition too.[2] Recently, Ferreira and Jafferany have proposed newer classification based on the conceptual difference between “disease” and “illness.” “Disease” would correspond to what is more objectively diagnosed (or visible). “Illness” would be a wider concept, focused more on what is less visible: the subjective experience of having a disease or objectively considered minor symptoms. A psychodermatological disorder could be, then, classified into the following three groups: (a) primary disease: when there is a primary dermatosis; (b) primary illness: when there are skin symptoms, with or without secondary self-induced skin lesions (such as excoriations), without a primary dermatosis; and (c) secondary disorder: skin disease, skin symptoms or mental illness: linked with exogenous factors drug reactions connecting dermatology and psychiatry.[38],[39] The most commonly used is presented in [Table 1].[37]
Table 1: Classification of psychodermatological disorders from Jafferany and França[37] Team The dermatology–psychiatry liaison concept, a multidisciplinary approach for the treatment of psychodermatologic patients, originated in Europe.[8],[9],[10] The concept of such a liaison clinic is only nascent in India since August 2010.[40] Patients with Psychodermatology diseases are best managed by a multidisciplinary team consisting of dermatologist to handle cutaneous disorders, psychiatrists for the management of concomitant psychiatric disease and a dedicated psychologist to facilitate appropriate psychological therapy, specialized nurses, primary care physicians, and also other allied health professionals.[41]
Clinicians with level 1 skill are capable of identifying minor mental health problems. They can assess patient's quality of life by DLQI, advice a systematic care plan with resources for self-management of medications and sleep. Level 2 skilled professionals can assess those with moderate distress to obtain the details of their mood or behavior. The treatment includes low-intensity cognitive behavioral therapy (CBT), lifestyle modification, and stress management that can be difficult for self-management. Practitioners with level 3 skills will manage patients with severe distress (e.g., body dysmorphic disorder or severe depression). An in-depth mental health assessment is done and management requires training in high-intensity CBT, interpersonal therapy, and specific depression or psychosis treatment.[41],[42][Figure 2] shows the general algorithm structure used by these clinics.[26]
Figure 2: Stepped provision of psychodermatology services from Zhou et al.[42] CBT. CBT: Cognitive-behavioral therapy. Consultation The requirements of each psychodermatology unit will depend on the type of patients seen. There are three existing models for the consultation: dermatologist as the only physician directly involved in patient's care; dermatologist and psychiatrist working together in the same room; dermatologist and psychiatrist working in conjunction, but in different rooms.[41] The advantages and disadvantages of these three models are summarized in [Table 2].
Table 2: Advantages and disadvantages of the three clinical provision models from Aguilar-Duran et al.[40]The lack of psychodermatology clinics currently makes cost analyses difficult, as there are very few effective comparators. However, evidence suggests that patients with psychocutaneous disease use large amounts of NHS resources (largely due to extensive and often unnecessary investigations, specialist referrals, and “doctor-shopping”). Specialist units reduce this cost, thus there are positive indicators of the financial viability of psychodermatology services.[41] The main reason for the cost-effectiveness of psychodermatology clinics is the access to multidisciplinary specialists and also a holistic approach to management. Unnecessary investigations and referrals are avoided. This service if provided by an in-house psychodermatology clinic would create rapport, enable integration of care, and promote the link between skin and psyche.[41]
Treatment ApproachesThere can be overlap in psychodermatology patients due to complex biopsychosocial factors, and they are recalcitrant to treatment. Dermatologists may find their management challenging, time-consuming, and aversive.[10],[39] Hence, a multidisciplinary collaborative approach is better over a simple referral to a psychiatrist. Consultation-liaison clinic is the ideal approach to give integrated care by dermatologists, psychologists, and psychiatrists.[43] These psychodermatology patients require the evaluation of skin lesions, exclusion of other diagnoses, appropriate laboratory tests, and a thorough evaluation of their social, familial, and occupational issues to optimize trust and therapeutic rapport with the patient.[20],[43],[44]
Psychodermatology clinic model is cost-effective; due to avoidance of unnecessary investigations, appropriate dermatology, and psychiatric management in one visit. Thus, mitigating psychiatry referral and stigma of being labeled as mentally ill lead to better patient compliance.[26] Treatment approach for psychodermatological disorders should start with a good rapport between doctor and patient to develop empathy, increase patient adherence and satisfaction.[45] Some goals that should be targeted while treating patients with psychodermatological disorder include:
Reduce physical distressDetect and improve sleep disturbancesDetect and treat psychiatric symptoms such as depression and anxietyManage social isolation/withdrawalImprove self-esteemImprove functioning.[46]We authors also suggest a new model in lines of Psychodermatology clinics, dermatologist can involve psychiatric and psychologist services online or by teleconsultation mode. The involvement of this mode will be cost-effective, more comfortable, usage of time efficiently, and patient compliance. Involvement of new technique and legalization of usage of teleconsultation has eased the availability and accessibility of the specialist.
The objectives of the British Association of Dermatologists' Psychodermatology Working Party report:[47]
To identify the needs (rather than wants) of patients with psychocutaneous diseaseTo identify minimum resources and standards to which all dermatology departments can have accessTo identify the resources that are available outside dermatology clinicTo identify and bring together different aspects of a multidisciplinary teamTo identify training requirements and resources for dermatologists and healthcare professionals deal with psychodermatology patientsTo support academic excellence in research of psychocutaneous diseases.Both nonpharmacological and pharmacological therapeutics have been used successfully. These can be used alone or in combination, depending on the medical evaluation and customized to each patient. Psychotherapy, cognitive behavioral therapy, hypnosis, stress management techniques, relaxation training, transcendental meditation, and biofeedback are some of the nonpharmacological approaches that have been successfully employed.[39] In skin picking disorder (dermatillomania) which is classified under obsessive–compulsive and related disorder is more beneficial with habit reversal training. These nonpharmacological therapies produce neurochemical, neurophysiological, and cognitive-behavioral effects in its practitioners. It decreases anxiety and stress (due to the decrease in cortisol and norepinephrine levels), increases feeling of pleasure and well-being (due to an increase in synthesis and release of dopamine and serotonin).[48],[49]
Pharmacological drugs used include antidepressants, anxiolytics, antipsychotics, immunosuppressants, antihistamines, oral or systemic corticosteroids, and other topical medications. The choice of a drug is based on psychopathology that can be compulsion, psychosis, anxiety, or depression [Table 3]. The most commonly used are selective serotonin reuptake inhibitors, serotonin–norepinephrine reuptake inhibitors, mood stabilizers, and antipsychotics. Antipsychotics can be used either to augment the efficacy of other medicines or as monotherapy in certain conditions such as delusions of parasitosis and trichotillomania. Other commonly used psychiatric medications include gabapentin in postherpetic neuralgia, naltrexone for pruritus, and lamotrigine/topiramate to treat skin picking. There are few controlled trials conducted with the above-mentioned pharmacological agents with variable results.[39]
Table 3: Psychotropics and important cutaneous adverse effects from Jafferany[49] Indian Scenario Psychodermatology is relatively a new branch of dermatology in India. The origin of psychodermatology in India can be traced to Buddha's period (circa 563-483 BCE).[50] Indigenous medical systems, such as Ayurveda, Yoga, and Unani, advocate control of skin disease through meditation, exercises, and related practices but scientific approach to psychodermatology is still lacking in India. The first dedicated psychodermatology liaison clinic was established in 2010 in Manipal.[3] and later, in Faridkot, Punjab, India.[51] The common problems encountered have been anxiety, dysthymia, and depression, especially in patients with psoriasis, vitiligo, and urticaria. However, dermatologists do refer extreme cases such as trichotillomania, body dysmorphic disorder, and delusional parasitosis to psychiatrists, as dedicated psychodermatology liaison service is woefully lacking. The Indian scenario is evolving by conducting workshops and continuing medical education programs and psychodermatology sessions in national dermatology conferences in India. The patients who were reluctant for independent psychiatry consultation were readily agreeing for psychodermatology consultation in liaison clinic with better compliance and satisfaction. Patients' management with counseling of parents and spouses was also found beneficial for the psyche of the patient.[52]
With the growing acceptance and research on psychodermatology, it is an opportunity to identify dermatologists' gap in knowledge, improve organizational structures by providing liaison clinics, integration of resources, and logistics to provide better service. Future research activities are required to evaluative clinic-focused quality metrics such as cost-benefit analyses, productivity, risk analysis, and practice sustainability. The educational model of a psychodermatology clinic is a promising approach. Residency training programs in psychodermatology to be a part of the curriculum. The establishment of an internationally recognized training program for psychotherapy at the dermatology practice level could be a possible alternative.[26]
Future directions
With this new pandemic era of COVID-19, there have been new innovative techniques to reduce the gap between patients and doctors. We can utilize teleconsultation model in psychodermatology to improve the QOL of these patients. Dermatologists can have a liaison with psychiatrist and psychologist through this portal. This will lead to a holistic approach, where all three specialties can be accommodated under one roof, thus improving the treatment compliance of these patients. To improve the training sessions of dermatologists in the field of psychiatry by having rotational postings for better understanding of the psychodermatological disorders. Workshops, continued medical education, and webinars would improve the knowledge of specialists of all three specialties, thus heightening the skill and knowledge in approach and management of these patients.
ConclusionIt is well established that “brain–skin axis” is responsible for the close relationship between skin involvement in psychiatric disorders and vice versa.[41] Psychodermatology field is trending, but the resources are limited globally. There is evidence that dedicated Psychodermatology services are cost-effective. This article tries to highlight the importance of understanding psychosomatic problems and to develop a continuing medical education program to all health-care professionals. We hope that the dermatologists will unravel their knowledge and attitude for better interaction with patients of skin diseases and psychological problems.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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