Psyche and skin: What's new?

Picardi A, Abeni D, Renzi C et al. Treatment outcome and incidence of psychiatric disorders in dermatological outpatients. J Eur Acad Dermatol Venereol 2003; 17: 155–159. In this issue of the Journal of the European Academy of Dermatology and Venereology, Picardi et al. (pp. 155–159) specifically addressed the question how frequently emotional alterations occur in dermatological patients. In a previous study by the same authors they showed that the prevalence of emotional disorders was 25.2% in about 2500 out-patients of a dermatological hospital.1 A higher prevalence (more than 30%) was found especially in patients with skin diseases such as acne, pruritus, urticaria and alopecia as well as in subjects without objective signs of dermatological disease. In our own study2 in which we sent questionnaires to 69 dermatology clinics, the directors reported a subpopulation of dermatology patients with psychosomatic disorders of about 23%, which corresponds well with Picardi's results. In nearly all dermatoses except hyperhidrosis and seborrhoeic eczema, we found that the extent of emotional influences is assumed to be higher than in a similar study performed 10 years before. Awareness of the influence of emotional disorders in skin patients appears to have made its way even into dermatological practice. The psychological distress of dermatological in-patients and the need for psychotherapeutic interventions has been studied by Fritzsche et al.3 who investigated 86 patients from one unit at a university dermatology department. Using the ICD-10 criteria they found in 46% mental and behaviour disorders, the most frequent being mood and anxiety disorders. Depression and anxiety are mostly risk factors for several skin diseases, as can be seen in recent studies on psoriasis vulgaris,4 lichen planus5 or Behçet's disease.6 Professional assessment indicated a need for psychotherapeutic treatment in 51%, and while 28% of the patients wished for psychotherapy, actual intervention occurred in 38%.3 The authors concluded that the need for psychotherapeutic treatment can only be handled within the framework of a liaison service in close collaboration with care givers. Other investigators also estimated a prevalence of psychosomatic disorders in dermatological patients of 28%7 up to 31%.8 On the other hand, those numbers of psychosomatic disorders are within the range of percentages in representative samples of the normal population and did not indicate a much higher prevalence in dermatological patients in particular. One area of recent research in skin and the psyche is the relationship between stress and dermatological diseases: Chrousos9 showed the general relationship between stress, chronic skin inflammation and emotional reactions and thus provides an introduction to an area that Buske-Kirschbaum et al.10 have examined more closely, especially for atopic eczema. The exciting topic of relationships between stress, endocrine and immunological reactions, and postulated hypotheses of changes in the brain have now been collated. Also, in alopecia areata, stress seems to play a part in the upregulation of corticotrophic releasing hormone receptors.11 Katasarou-Katsari et al.11 investigated the expression of corticotrophic releasing hormone receptors on the affected skin of patients in comparison with normal volunteers who showed weak background expression of all three receptor types that have been investigated. The patients who were studied showed intense expression only to the type 2β receptor around the hair follicles, and the authors concluded that acute emotional stress may precipitate alopecia areata. A recent study has also pointed out that stress can also influence psoriasis.12 A similar reaction with regard to atopic eczema was shown by Kodama et al.13 who investigated atopic eczema patients after the Great Hanshin earthquake in Japan and compared more than 1500 patients with patients who were not affected by the earthquake. Those patients who were stressed had significantly greater numbers of exacerbation of their atopic eczema than the controls. Also mice studies with contact hypersensitivity experimentally showed reactions of stress-induced influences.14 There is, therefore, no longer doubt that psychosomatic cofactors influenced skin symptoms. Quality of life studies recently have been given more attention in dermatological illness. Not surprisingly, studies showed that there was no correlation between subjective impairment and clinical improvement. A recent study on acne patients15 demonstrated in 50 females with acne and clinical treatment with oral contraceptives over a 9-month period that the perceived psychosocial impairment is individually based, and greater in women who subjectively overrate their acne. In genetically determined skin diseases, such as neurofibromatosis quality of life impairment in patients with more severe symptoms reported more effects on their general health quality of life. The consequences of visibility and severity from the viewpoint of patients can be evaluated using questionnaires, such as Skindex or Short Form-36.16 An overview has been published by Halioua et al.17 who presented the available quality of life measurements in dermatology in the light of methodical criteria of test validity. In examining quality of life in dermatological patients, it was found that in both hospitalized and out-patients, quality of life is most limited in patients with atopic eczema, psoriasis and pruritus, and least in acne patients.18 Harlow et al.19 found the same limitations, to a somewhat lesser extent, in patients with dermatological complaints in general primary care practices. Highly interesting are the neurological bases of skin reactions. Undem et al.20 have written an overview of neural integration in allergic diseases and thus pointed out the multiplicity of relationships between allergic diseases and neural processes. In a study by Andrew and Craig21 an age-old battle took on new life as the authors demonstrated selective neuronal transmission pathways for itching, and thus questioned the theory that itching is transmitted via pain fibres! But also tactil spatial discrimination and cutaneous coding properties by skin hydration in elderly people can be demonstrated using modern techniques of brain research.22 And if that is not enough, a curious human reaction, the amnestic block syndrome, in which a person suddenly and with no apparent trauma or illness, forgets who he/she is and what he/she has done, illustrates that even asthma and allergy may completely disappear in the presence of such rare brain changes. Markowitsch et al.23 described the case of a man who could no longer find his way home after he went to the bakery. After a vagabond life for a few days, he had forgotten his family, his house, his occupation – and also his allergic reactions. This case, which is a clear illustration of an exceptional reaction, gives us cause to remember that it is, in principle possible to influence an allergy by means of changes demonstrable in positron emission tomography. One relationship that is drawing increasing attention in clinical practice is that of comorbidity of allergy and phobia: some patients develop massive phobias due to underlying or comorbid anxiety disorders, although allergies have been ruled out or potential allergens have been eliminated. In such cases well-intentioned allergological advice is actually counterproductive or even contraindicated. Although no longer completely up to date, a study by Schmidt-Traub and Bamler24 has clearly demonstrated that anxiety disorders are significantly more often found in type 1 allergic patients than in the healthy control group. The outlined aspects about skin and psyche showed that there have been many scientific studies published in the recent years. Psychosomatic dermatology is, therefore, developing, and has to be recognized by all dermatologists!