When you're mentally worn out from a tough week at work, a disagreement with a friend or just a long day, there are probably some steps you'll take to relax. You might have a bubble bath, talk to a friend or take a day off from your job. However, what if your skin is trying to tell you that it needs a break. A pesky breakout or itchy rash may be a sign that your skin is also fed up with whatever is stressing you out. Irritated skin usually sends people running to the chemist for quick relief, but a rising trend has some heading to therapists who specialise in psychodermatology -- therapists for your skin.
Psychodermatology is an approach to treating skin conditions that addresses the connection between mind and body and, in doing so, examines disorders that are exacerbated by psychological or emotional stress. The field's practitioners study the external stressors that often trigger skin conditions or inhibit the body's healing process. With these stressors in mind, a therapist creates a treatment plan that can involve anything from yoga to self-hypnosis, often in tandem with more traditional dermatology therapies, such as antibiotics. Although psychodermatology has been growing in popularity, it may be more effective for conditions that aren't responding well to medical treatment than for conditions that do.
Research has shown clear links between skin diseases and psychological factors. In one study, 50 to 90% of patients with chronic conditions, like psoriasis, acne, eczema and rosacea, had emotional triggers. This evidence is one of psychodermatologists' major arguments. They believe that these emotional stressors can make traditional medicines less effective, so removing the stressors has to be part of a patient's treatment. The American Academy of Dermatology concluded that when dermatologists treat both skin and the source of stress, the skin clears more quickly as stress decreases.
• Stress can manifest itself in one’s appearance in many ways, but primarily by making the skin more sensitive and more reactive. For example, stress can make psoriasis or rosacea worse, result in acne lesions that are more inflamed and more persistent, cause brittle nails and ridging of the nails, cause hair loss, cause or worsen hives, and cause excessive perspiration. Stress also is a known trigger or can be a worsening factor for fever blisters, psoriasis, seborrheic dermatitis and has even been shown to impair skin barrier function and dehydrate the skin – allowing more irritants, allergens, and infectious agents to penetrate the skin and cause problems.
• Beyond the direct physiological effects of stress, patients under stress also tend to neglect or abuse their skin. For example, they often lack the energy and motivation to adhere to their skin-care regiments, and there also might be signs of stress-related behaviours – such as scratching, pulling or rubbing – that can exacerbate problems.
• Traditional dermatologic therapies should be used in conjunction with appropriate stress management therapies to successfully treat stress-related dermatologic conditions. When dermatologists treat both the skin and stress, the skin often clears more quickly and completely as the influences of stress are diminished. This, in turn, can help decrease a patient’s overall anxiety level, and the patient may start to feel better about how they look and how they feel emotionally.
• On a microscopic level, stress reduction can decrease the release of proinflammatory stress hormones and chemicals. For example, release of neuropeptides (or stress chemicals released from the nerve endings) can be reduced with stress management techniques. This often results in skin that looks and functions better. These interventions can reduce blood vessel over-activity, resulting in less blushing or flushing.
• With accurate diagnosis by a dermatologist, effective treatments improve the appearance and function of the skin. This alone can substantially reduce patients’ stress and improve their skin, hair and nail conditions. However, if stress is clearly interfering with patients’ overall well-being and ability to cope, simultaneous stress management interventions are warranted.
Hypnosis for skin conditions
Hypnosis can be used to increase healthy behaviours, to decrease situational stress, to reduce needle phobias, to control harmful habits (eg, scratching), to provide immediate and long-term analgesia, to ameliorate symptoms related to diseases (eg, pruritus), to accelerate recovery from surgery, and to enhance the mind-body connection to promote healing. Hypnosis can be especially helpful in dealing with skin diseases that have a psychosomatic aspect.
Direct suggestion while in the hypnotic state is a frequently used method of decreasing discomfort from pain, pruritus, burning sensations, anxiety, and insomnia. Again, post-hypnotic suggestion and repeated use of an audio-cassette tape for self-hypnosis help to reinforce the effectiveness of direct suggestion. Direct suggestion may produce a sufficiently deep anesthesia in highly hypnotisable individuals for cutaneous surgery. Direct suggestion can also be used to reduce repetitive acts of skin scratching or picking, nail biting or manipulating, and hair pulling or twisting. Unwanted psychophysiologic responses, such as hyperhidrosis, blushing, and some types of urticaria, can also be controlled by direct suggestion. Some skin lesions can even be induced to resolve by using direct suggestion; the classic example is verrucae.
Symptom substitution retrains the subconscious by means of hypnosis to replace a negative habit pattern with a more constructive one. For example, scratching can be replaced by another physical activity, such as grabbing onto something and holding it so tightly for a half minute that it almost hurts. Other stress relievers that can be substituted for scratching include athletic activities, artwork, verbal expression of feelings, or meditation.
Hypnotic Relaxation During Dermatologic Surgery
A variety of dermatologic procedures can produce pain or anxiety in patients. Skin procedures that are somewhat painful but usually do not require a local anaesthetic include moderate depth chemical peels, cryodestruction of skin lesions, curettage of molluscum, excision of skin tags, extrusion of comedones, incision and expression of milia, laser treatment of vascular lesions, strong microdermabrasion, and sclerotherapy. Dermatologic procedures that require a local anaesthetic include electrodesiccation and curettage, incision and drainage of an abscess, laser ablation of skin lesions, liposuction, punch biopsy, shave biopsy, surgical excision, and surgical repair. Cutaneous procedures that may require conscious sedation include deep chemical peels, dermabrasion, laser resurfacing, and extensive liposuction. All of these procedures may be augmented by hypnotic relaxation and/or hypnotic analgesia.
Hypnosis for Specific Dermatologic Conditions
The early report by Sulzberger on the efficacy of suggestion in treating warts has since been confirmed numerous times. Numerous reports attest to the efficacy of hypnosis in treating warts. In a well-conducted randomized controlled study by Spanos et al that serves as a typical example, 53% of the experimental group had improvement of their warts 3 months after the first of 5 hypnotherapy sessions, while none of the control group had improvement. Hypnosis can be successful as a therapy for warts.
Stress is often a factor in the onset, exacerbation, and prolongation of psoriasis. Hypnosis and suggestion have been shown to have a positive effect on psoriasis. In a typical case report, 75% clearing of psoriasis was reported by using a hypnotic sensory-imagery technique. A case of extensive, severe psoriasis of 20 years' duration showed marked improvement by using sensory imagery to replicate the sensations in the patient's skin that he had experienced during sunbathing. Another case of severe psoriasis of 20 years' duration fully resolved with a hypnoanalytic technique.
Tausk and Whitmore performed a small randomized double-blind controlled trial by using hypnosis as adjunctive therapy in psoriasis, with significant improvement in individuals who were highly susceptible to hypnosis. Hypnosis can be useful as an adjunct therapy for resistant psoriasis, especially if an emotional factor is significant in the triggering of the psoriasis.
Venipuncture in children
Liossi et al conducted a prospective, randomized, controlled trial to compare the efficacy of a local anesthetic (EMLA), EMLA plus hypnosis, or EMLA plus attention in children receiving venipuncture. Children in the EMLA-plus-hypnosis group reported less anticipatory anxiety and less procedure-related pain and anxiety; they were rated as demonstrating less behavioural distress during the procedure than patients in the other 2 groups. Additionally, parents whose children were randomized to the EMLA-plus-hypnosis group experienced less anxiety during their child's procedure than parents whose children had been randomized to the other 2 groups.
Stewart and Thomas treated 18 adults with extensive atopic dermatitis whose conditions had been resistant to conventional treatment with hypnotherapy. In a non-randomized controlled study, they used relaxation, stress management, direct suggestion for non-scratching behaviour and for skin comfort and coolness, ego strengthening, post-hypnotic suggestions, and instruction in self-hypnosis. The results were statistically significant for reduction in itching, scratching, sleep disturbance, and tension. The use of topical corticosteroids decreased from the original amount by 40% at 4 weeks, 50% at 8 weeks, and 60% at 16 weeks. For milder cases of atopic dermatitis, hypnosis, along with moisturising, can be sufficient as a primary treatment. For more extensive or resistant atopic dermatitis, hypnosis can reduce the required amount of other conventional treatments.
Gupta et al found a strong correlation between high stress reactivity and depression in patients with alopecia areata. Willemson et al used hypnotherapy for 21 patients, 9 with alopecia universalis and 12 with extensive alopecia areata. After hypnotherapy, all patients had significantly lower anxiety and depression. Complete scalp hair regrowth occurred in 9 patients, including 4 with alopecia universalis and 2 with ophiasis. Over 75% scalp hair regrowth occurred in another 3 patients. Five patients had a significant relapse of alopecia. Hypnosis is appropriate as a stress reducer and sometimes is successful as a primary treatment method for alopecia areata.
Two cases of urticaria responding to hypnotic suggestion were reported in a study. The study included an 11-year-old boy whose urticarial reaction to chocolate could be blocked by hypnotic suggestion so that hives appeared on only one side of his face in response to that hypnotic suggestion. A case series study of hypnosis with relaxation therapy on 15 patients with chronic urticaria for an average duration of 7.8 years showed that within 14 months, 6 patients' conditions had cleared and 8 had improved, with decreased medication requirements reported by 80% of patients. One patient's condition did not improve. Hypnosis may be useful as a therapy for chronic urticaria.
Individual case reports:
Hollander reported success in controlling the picking aspects of acne excoriée in 2 cases by using post-hypnotic suggestion. While in a hypnotic state, the patient was instructed to remember the word scar whenever she wanted to pick her face and to refrain from picking by saying scar. The excoriations resolved but not the underlying acne. The author has also used this technique successfully. Hypnosis, combined with standard acne treatments for the acneiform aspects, may be an appropriate treatment of the excoriation aspect of acne excoriée.
Congenital ichthyosiform erythroderma
Several cases of remarkable clearing of congenital ichthyosiform erythroderma of Brocq have been reported following direct suggestion for clearing under hypnosis. For example, Kidd reported improvement in a 34-year-old father and his 4-year-old son. Hypnosis, in addition to the use of emollients, may potentially be useful.
Reduction in the severity of dyshidrotic dermatitis has been reported with the use of hypnosis as a treatment. Greisemer's data indicate a significant psychosomatic component for dyshidrosis; therefore, hypnosis may be useful as a therapy.
Resolution of erythema nodosum of 9-year duration occurred in a 44-year-old woman after hypnoanalysis. Five of the 7 key COMPASS factors were positive in this case.
One case report exists of successful treatment of erythromelalgia in an 18-year-old woman using hypnosis alone followed by self-hypnosis. Permanent resolution occurred.
Jabush described a 33-year-old man with recurrent (since age 17 years), multiple furuncles that contained Staphylococcus aureus; the furuncles were unresponsive to multiple treatment modalities. The patient had a negative self-image. Hypnosis and self-hypnosis with imagined sensations of warmth, cold, tingling, and heaviness resulted in dramatic improvement over 5 weeks, with full resolution of the recurrent furuncles. He also substantially improved from a mental standpoint. The hypnosis was hypothesized to have helped in some way to normalize the immune response to the bacteria. Conventional antibiotic therapy is the first line of treatment for furuncles; however, in unusually resistant cases with significant psychosomatic overlay, hypnosis may help to end the recurrent cycles of infection.
When oral pain has a psychogenic component, hypnosis may be effective as a primary treatment. Even with organic disease, hypnosis may temporarily relieve pain.
Lessening of discomfort from herpes simplex eruptions is similar to that for post-herpetic neuralgia. Reduction in the frequency of recurrences of herpes simplex following hypnosis has also been reported. In cases with an apparent emotional trigger factor, hypnotic suggestion may be useful as a therapy for reducing the frequency of recurrence.
Hypnosis and autogenic training may be useful as adjunctive therapies for hyperhidrosis.
A 33-year-old man with chronic ichthyosis vulgaris that was better in the summer and worse in the winter began hypnotic suggestion therapy in the summer and was able to maintain the summer improvement throughout the autumn, winter, and spring. Hypnosis may be useful as an adjunct therapy for ichthyosis.
Both the pruritus and the lesions may be reduced in selected cases by using hypnosis as a therapy for lichen planus.
Several cases of neurodermatitis have reportedly resolved by using hypnosis as a therapy. Neurodermatitis remained resolved, with up to 4 years of follow-up. Iglesias reported 3 cases of neurodermatitis that failed to respond to direct suggestion under hypnosis but that responded to hypnoanalysis with ideomotor signaling followed by reframing. Hypnosis may be useful as a therapy for neurodermatitis.
Reduction of pruritus and resolution of lesions have been reported with the use of hypnotic suggestion as complementary therapy for nummular dermatitis.
The pain of acute herpes zoster and post-herpetic neuralgia can be reduced by hypnosis. Hypnosis may have a place as a therapy for post-herpetic neuralgia.
The intensity of pruritus may be modified and improved by hypnosis. For example, a man with chronic myelogenous leukemia had intractable pruritus, which improved with hypnotic suggestion. Hypnosis may be used as a therapy for intractable pruritus.
Improvement of rosacea, especially the vascular blush component, has been reported in selected cases of resistant rosacea where hypnosis has been added as a therapy.
Several cases of successful adjunctive treatment of trichotillomania with hypnosis have been reported. Hypnosis may be a useful therapy for trichotillomania.
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