Philip D. Shenefelt

Biofeedback, cognitive-behavioral methods, and hypnosis in dermatology: is it all in your mind?

ABSTRACT:  Biofeedback can improve cutaneous problems that have an autonomic nervous system component. Examples include biofeedback of galvanic skin resistance (GSR) for hyperhidrosis and biofeedback of skin temperature for Raynauds disease. Hypnosis may enhance the effects obtained by biofeedback. Cognitive‐behavioral methods may resolve dysfunctional thought patterns (cognitive) or actions (behavioral) that damage the skin or interfere with dermatologic therapy. Responsive diseases include acne excoriée, atopic dermatitis, factitious cheilitis, hyperhidrosis, lichen simplex chronicus, needle phobia, neurodermatitis, onychotillomania, prurigo nodularis, trichotillomania, and urticaria. Hypnosis can facilitate aversive therapy and enhance desensitization and other cognitive‐behavioral methods. Hypnosis may improve or resolve numerous dermatoses. Examples include acne excoriée, alopecia areata, atopic dermatitis, congenital ichthyosiform erythroderma, dyshidrotic dermatitis, erythromelalgia, furuncles, glossodynia, herpes simplex, hyperhidrosis, ichthyosis vulgaris, lichen planus, neurodermatitis, nummular dermatitis, postherpetic neuralgia, pruritus, psoriasis, rosacea, trichotillomania, urticaria, verruca vulgaris, and vitiligo. Hypnosis can also reduce the anxiety and pain associated with dermatologic procedures.

Pyoderma gangrenosum in a patient with cryoglobulinemia and hepatitis C successfully treated with interferon alfa

We describe a patient with long-standing pyoderma gangrenosum unresponsive to therapy. The patient had concomitant cryoglobulinemia and hepatitis C. When the hepatitis C was treated with interferon alfa-2a his pyoderma gangrenosum resolved. Whether this was from the interferon alfa or spontaneous resolution is not known.

Psychodermatological disorders: recognition and treatment

Many dermatological disorders have a psychosomatic or behavioral aspect. Skin and brain continually interact through psychoneuroimmunoendocrine mechanisms and through behaviors that can strongly affect the initiation or flaring of skin disorders. It is important to consider these mind‐body interactions when planning treatments for specific skin disorders in individual patients. Mind‐influencing therapeutic options that can enhance treatment of skin disorders include standard psychotropic drugs, alternative herbs and supplements, the placebo effect, suggestion, cognitive‐behavioral methods, biofeedback, and hypnosis. When individual measures do not produce the desired results, combinations of drugs or addition of non‐drug therapies may be more successful. Psychophysiological skin disorders may respond well to non‐drug and drug therapies that counteract stress. Treatment of primary psychiatric disorders often results in improvement of associated skin disorders. Psychiatric disorders secondary to skin disorders may also require treatment. Therapeutic options for each of these are discussed.

Psychological interventions in the management of common skin conditions.

The nervous system and the skin develop next to each other in the embryo and remain intimately interconnected and interactive throughout life. The nervous system can influence skin conditions through psychoneuroimmunoendocrine mechanisms and through behaviors. Understanding the pathophysiology aids in selection of treatment plans for correcting the negative effects of the psyche on specific skin conditions. Medication options include standard psychotropic medications and alternative herbs and supplements. Other options include biofeedback, cognitive-behavioral methods, hypnosis, meditation, progressive relaxation, the placebo effect, and suggestion. When simple measures fail, combining medications with other therapeutic options may produce better results. Skin conditions that have strong psychophysiologic aspects may respond well to techniques such as biofeedback, cognitive-behavioral methods, hypnosis, meditation, or progressive relaxation that help to counteract stress. Treatment of primary psychiatric disorders that negatively influence skin conditions often results in improvement of those skin conditions. Abnormal conditions of the skin, hair, and nails can also influence the psyche negatively. Treatment of secondary psychiatric disorders such as anxiety or depression that are triggered or exacerbated by the appearance of these skin conditions or the associated discomfort may also be required.

Limits of ICD-9-CM code usefulness in epidemiological studies of contact and other types of dermatitis.

BACKGROUND International Classification of Diseases, Version 9, Clinical Modification (ICD-9-CM) coding information used for billing is readily available in computerized form. OBJECTIVES The purpose of this article is to determine the usefulness of ICD-9-CM codes in a descriptive dermatoepidemiological study of contact and other dermatitis. METHODS Prospective recording of specific dermatologic diagnoses and the ICD-9-CM code assigned for each diagnosis was performed for all patient visits to the authors dermatology clinics for 6 months. RESULTS There were 2,524 patient visits with 4,451 diagnoses, of which 789 diagnoses were dermatitis. The 10 different diagnostic categories of dermatitis had eight associated ICD-9-CM codes. Allergic contact dermatitis with 247 visits, irritant contact dermatitis with 30 visits, and nummular dermatitis with 61 visits shared one diagnostic code. Thus, 43% of visits for dermatitis were intermixed by having the same ICD-9-CM code. CONCLUSION Lack of one-to-one correspondence of ICD-9-CM codes with dermatitis diagnostic categories creates a situation in which ICD-9-CM codes are not useful for dermatoepidemiological studies of contact and other types of dermatitis. This could be corrected by assigning additional five-digit ICD-9-CM codes to cover each type of dermatitis. Coding for specific allergens or irritants is not feasible with the current five-digit ICD-9-CM codes.

Anxiety Reduction Using Hypnotic Induction and Self-Guided Imagery for Relaxation During Dermatologic Procedures

Abstract Many patients experience some degree of anxiety during dermatologic procedures. A prospective, randomized-control trial of hypnotic induction followed by self-guided imagery was conducted with patients in 3 groups: live induction, recorded induction, or control. By 20 minutes into the procedure, there was significantly reduced anxiety reported in the live-induction group compared with the control, whereas reported anxiety in the recorded-induction group was similar to that of the control group. All 13 in the live induction, 11 of the 13 in the recorded induction, and none of the 13 in the control group imagined scenes. The findings of this study suggest that live hypnotic induction followed by self-guided imagery can help to reduce anxiety experienced by many patients during dermatologic procedures.

Psychocutaneous hypnoanalysis: detection and deactivation of emotional and mental root factors in psychosomatic skin disorders.

Abstract Many skin disorders have a significant psychosomatic component. Focused history-taking coupled with hypnoanalysis using ideomotor finger signals to detect positive responses to one or more of 7 common triggering or exacerbating factors permits systematic diagnosis of the presence or absence of a significant psychosomatic component. If no factor is positive, a psychosomatic component to the skin disorder can likely be excluded. If one or two of the 7 factors are positive and it is possible to identify the initiating event, treatment by reframing with suggestions in hypnosis may succeed in defusing the associated negative emotional impact associated with the psychosomatic component of the skin disorder. This may be sufficient to uproot and weed out the problem. However, if a multiple of the 7 factors are positive as in the included case report, referral to an appropriate psychotherapist is recommended.

Descriptive epidemiology of contact dermatitis in a university student population

BACKGROUND The frequency of irritant and allergic contact dermatitis has been compared in relatively few studies. OBJECTIVE This report describes the frequency of visits by university students to campus prepaid health plan dermatologists for irritant and allergic contact dermatitis compared with visits for other types of dermatitis and other skin problems. METHODS Prospective recording of specific dermatologic diagnoses was performed for all visits of students to student health service dermatologists. Diagnoses were then tabulated, rank ordered, and compared. RESULTS Irritant dermatitis represented 2.3% of all first visits and 1.6% of all total visits. Allergic contact dermatitis accounted for 3.1% of all first and 2.4% of all total visits. Other types of dermatitis were found in 12.5% of all first and 11.1% of all total visits. Contact dermatitis ranked first among types of dermatitis, being seen in 30.0% of first visits for dermatitis and in 27.0% of total visits for dermatitis. CONCLUSION In this prospective study, contact dermatitis represented a relatively large proportion of visits for dermatitis. Slightly more allergic than irritant contact dermatitis was found. This is at variance with findings in industrial settings that irritant dermatitis generally is more common than allergic contact dermatitis.

Spiritual and religious aspects of skin and skin disorders.

Skin and skin disorders have had spiritual aspects since ancient times. Skin, hair, and nails are visible to self and others, and touchable by self and others. The skin is a major sensory organ. Skin also expresses emotions detectable by others through pallor, coldness, “goose bumps”, redness, warmth, or sweating. Spiritual and religious significances of skin are revealed through how much of the skin has been and continues to be covered with what types of coverings, scalp and beard hair cutting, shaving and styling, skin, nail, and hair coloring and decorating, tattooing, and intentional scarring of skin. Persons with visible skin disorders have often been stigmatized or even treated as outcasts. Shamans and other spiritual and religious healers have brought about healing of skin disorders through spiritual means. Spiritual and religious interactions with various skin disorders such as psoriasis, leprosy, and vitiligo are discussed. Religious aspects of skin and skin diseases are evaluated for several major religions, with a special focus on Judaism, both conventional and kabbalistic.

Complementary psychotherapy in dermatology: hypnosis and biofeedback

Hypnosis has been used for millennia to treat medical and dermatologic problems. The use of biofeedback is more recent, being dependent on instrumentation to measure such parameters as galvanic skin resistance (GSR) and skin temperature. Numerous dermatologic disorders may be improved or cured using hypnosis as an alternative or complementary therapy. Examples include acne excoriee, alopecia areata, atopic dermatitis, congenital ichthyosiform erythroderma, dyshidrotic dermatitis, erythromelalgia, furuncles, glossodynia, herpes simplex, hyperhidrosis, ichthyosis vulgaris, lichen planus, neurodermatitis, nummular dermatitis, postherpetic neuralgia, pruritus, psoriasis, rosacea, trichotillomania, urticaria, verruca vulgaris, and vitiligo. Dermatologic procedure anxiety can also be reduced using hypnosis. Skin problems that have an autonomic nervous system component can be assisted by biofeedback with or without hypnosis. Examples include biofeedback of GSR for hyperhidrosis and biofeedback of skin temperature for Raynaud’s syndrome. Hypnosis may enhance the effects obtained by biofeedback.