Chronic Tender Ulcers on the Calf and Both Forearms.

An elderly woman presented with a 3-month history of nonhealing, tender ulcers involving the right calf and both forearms. She denied any history of similar lesions or trauma. Two trials of oral antibiotics had led to no improvement. Her medical history was significant for rheumatoid arthritis treated with methotrexate, hydroxychloroquine, and prednisone. A review of clinical manifestations was otherwise negative for disease. Physical examination of the patient's right calf revealed two punched-out ulcers with central necrotic black eschars, underlying retiform purpuric pattern, and mild fibrinopurulent drainage (Figure 1). Similar lesions were present on her forearms (Figures 2 and 3). No other remarkable skin changes were noted. The differential diagnosis included polyarteritis nodosa, cutaneous necrosis secondary to antiphospholipid syndrome, cryoglobulinemic vasculitis, and an atypical presentation of pyoderma gangernosum.

Disseminated histoplasmosis in a renal transplant patient.

Histoplasma capsulatum is a common endemic mycosis. Infection typically goes unnoticed by an individual, but in immunosuppressed patients, it may become disseminated. We report a case of disseminated histoplasmosis occurring 6 weeks after a kidney transplant. We discuss disseminated histoplasmosis and review its characteristic clinical, laboratory, and histologic manifestations, as well as current treatment modalities.

Current Practices, Experiences, and Views in Clinical Hypnosis: Findings of an International Survey.

An online survey of 691 clinicians who use hypnosis was conducted in 31 countries to gain a broad real-world picture of current practices, views, and experiences in clinical hypnosis. Among 36 common clinical uses, stress reduction, wellbeing and self-esteem-enhancement, surgery preparations, anxiety interventions, mindfulness facilitation, and labor and childbirth applications were the most frequently rated as highly effective (each by ≥70% of raters) in the clinicians' own experience. Adverse hypnosis-associated effects had been encountered by 55% of clinicians but were generally short-lived and very rarely judged as serious. The most common hypnosis approaches used were Ericksonian (71%), hypnotic relaxation therapy (55%), and traditional hypnosis (50%). Almost all respondents reported regularly using other therapeutic modalities alongside hypnosis. Among a range of client variables potentially affecting therapy, most clinicians rated hypnotist-client rapport (88%) and client motivation (75%) as very or extremely important factors for successful hypnotherapy. The majority of respondents had conducted hypnosis treatment via teletherapy, and 54% of those estimated it to be as effective as in-person treatment.

Hypnosis to alleviate the symptoms of ciguatera toxicity: a case study.

Ciguatera toxicity is a poisoning from consuming reef fish that had fed on dinoflagellates such as Gambierdiscus toxicus found along coral reefs. The toxin is oil soluble, odorless, colorless, tasteless, heat stable, and is concentrated in larger carnivorous fish such as amberjack, barracuda, eel, grouper, red snapper, sea bass, and Spanish mackerel. Onset of symptoms is usually within 6-12 hours after ingestion. Gastrointestinal symptoms lasting 1-2 days include abdominal pain, nausea, vomiting, and diarrhea. Neurological symptoms may persist for weeks or several months or--rarely--years and include circumoral and extremity paresthesias, temperature sensation reversal, itching, weakness, ataxia, and others. A patient with burning hands and feet who had not found relief using other methods had diagnosis of ciguatera toxicity assisted by hypnotically refreshed memory followed by rapid relief with hypnotic suggestions in 1 session and remained free of symptoms.

Guidelines for the Assessment of Efficacy of Clinical Hypnosis Applications.

Research on the efficacy of hypnosis applications continues to grow, but there remain major gaps between the science and clinical practice. One challenge has been a lack of consensus on which applications of hypnosis are efficacious based on research evidence. In 2018, 6 major hypnosis organizations collaborated to form the Task Force for Establishing Efficacy Standards for Clinical Hypnosis. This paper describes a Guideline for the Assessment of Efficacy of Clinical Hypnosis Applications developed by the Task Force, which makes 10 specific recommendations. The guideline is intended to be a tool for those who want to assess the quality of existing evidence on the efficacy of clinical hypnosis for any particular indication. The paper also discusses methodological issues in the interpretation and implementation of these guidelines. Future papers will report on the other products of the Hypnosis Efficacy Task Force, such as best practice recommendations for outcomes research in hypnosis and an international survey of researchers and clinicians on current practice and attitudes about hypnosis.

An unusually large eccrine poroma: a case report and review of the literature.

The eccrine poroma is an uncommon benign neoplasm previously thought to originate solely from the eccrine sweat gland. Initially believed to present on hairless acral surfaces, a more extensive distribution has been described. We report a case of a 55-year-old man with a slowly growing, 6-cm eccrine poroma on the medial aspect of his right foot of 40 years' duration. Clinicians should be aware that poromas can be of either eccrine or apocrine origin and can occur in areas other than acral skin. They also should understand the subclassification of the poroma family of neoplasms.

Ideomotor signaling: from divining spiritual messages to discerning subconscious answers during hypnosis and hypnoanalysis, a historical perspective.

Ideomotor movements account for non-conscious motions of the hand held pendulum and Ouija board planchette that once were attributed to external spirits. Chevreul and Carpenter in the mid-1800s pioneered our scientific understanding of ideomotor movements. The intention or thought is transmitted to the motor cortex at a subconscious level, coordinated by the cerebellum, and sent down spinal nerves to the appropriate muscles, inducing micromovements not visible to the naked eye but amplified by the hand held pendulum or by the slow ratchet-like cumulative movements of a finger or other body part. This ideomotor phenomenon has been utilized during hypnotic trance to provide nonverbal communication of "yes" or "no" or "I don't want to answer" using finger signals or hand held pendulum. LeCron first used this ideomotor form of communication in conjunction with psychosomatic hypnoanalysis. Cheek expanded and more recently Hammond, Walsh, Ewin and others have refined its use.

Relaxation strategies for patients during dermatologic surgery.

Patient stress and anxiety are common preoperatively and during dermatologic procedures and surgeries. Stress and anxiety can occasionally interfere with performance of procedures or surgery and can induce hemodynamic instability, such as elevated blood pressure or syncope, as well as producing considerable discomfort for some patients. Detection of excess stress and anxiety in patients can allow the opportunity for corrective or palliative measures. Slower breathing, biofeedback, progressive muscular relaxation, guided imagery, hypnosis, meditation and music can help calm and rebalance the patient's autonomic nervous system and immune functioning. Handheld miniaturized heart rate variability biofeedback devices are now available. The relaxation response can easily be taught. Guided imagery can be recorded or live. Live rapid induction hypnosis followed by deepening and then self-guided imagery requires no experience on the part of the patient but does require training and experience on the part of a provider. Recorded hypnosis inductions may also be used. Meditation generally requires more prior experience and training, but is useful when the patient already is skilled in it. Live, guided meditation or meditation recordings may be used. Relaxing recorded music from speakers or headphones or live performance music may also be employed to ease discomfort and improve the patient's attitude for dermatologic procedures and surgeries.

Controversies in skin surgery: electrodessication and curettage versus excision for low-risk, small, well-differentiated squamous cell carcinomas.

BACKGROUND: Electrodesiccation and curettage (ED&C) of low-risk, cutaneous squamous cell carcinoma (SCC) generally consumes less time and resources than excision. Review of the literature reveals few recent studies examining cure rates for ED&C in the treatment of low risk cutaneous SCC. OBJECTIVE: To evaluate via two retrospective studies the efficacy of ED&C in the treatment of low risk cutaneous SCC. METHODS: A small controlled study in a Veterans Administration teaching hospital dermatology clinic compared cure rates of low risk SCC at one year by ED&C to those of surgical excision. A second study examined the cure rate of low risk lesions treated by curettage and electrodesiccation in a private practice. RESULTS: The first study found no significant difference in cure rates between ED&C (14 of 14 cases successfully treated) and excision (15 of 16 successfully treated and one recurrence) (P = 0.1711). The second study found the ED&C cure rate (106 of 106 successfully treated) to be significantly greater than an arbitrary cure rate of 95 percent (P = 0.0091). CONCLUSION: These findings support the efficacy of ED&C as a treatment modality for low-risk cutaneous SCC.

Topical corticosteroids in dermatology.

Topical corticosteroids are the most commonly prescribed agents in the treatment of dermatologic conditions. They are used primarily as monotherapy or in combination with other agents for enhanced efficacy. Several stronger preparations are now available since their first introduction. They are also available in various vehicles altering the potency and giving the option of tailoring them for use based on specific anatomic locations, area of involvement, age of the patient, and most importantly, severity of the condition. Several local and systemic side effects have been associated with their inadvertent use. Allergic contact dermatitis to most of the preparations has also been noticed. Judicious use with reinforced patient education lowers such risk for side effects, and can be of great use in treating dermatologic conditions.

Psychodermatology: An Association of Primary Psychiatric Disorders With Skin.

The association of nervous system with skin is well documented. Many common psychiatric disorders can involve skin either directly or indirectly. We found an association of 13 primary psychiatric disorders leading to dermatological diseases, with association of 2 of 13 considered to be idiopathic. Association of the mind and body has long been studied. Several skin problems lead to psychological and psychiatric symptoms, however not all skin problems lead to psychiatric symptoms. On the contrary, many primary psychiatric illnesses appear to have associated skin disorders.

A correlation of allergic contact dermatitis with allergen type and patient categorical variables.

Allergic contact dermatitis is a very treatable disease once it is diagnosed. In this study, statistical analysis was done on 105 patients with allergic contact dermatitis and the data were correlated with allergen type and patient categorical variables. Once allergens were identified, patients were advised to practice avoidance of the identified allergens. Significant differences in gender and past history of allergy were noted. Improvement after avoidance of identified allergens was also tracked, and a significant negative correlation was observed between number of allergens and improvement of patients' conditions. Although not reaching a statistical level of significance, some interesting trends were found regarding age versus severity and age versus improvement, which should be explored in future studies. In addition, a larger study population would ensure the collection of more statistically significant data for future research.

Mindfulness-Based Cognitive Hypnotherapy and Skin Disorders.

Mindfulness-based cognitive hypnotherapy integrates mindfulness, cognitive-behavioral therapy, and hypnotherapy to improve physical, emotional, mental, and/or spiritual aspects of skin disorders. Meditation, including mindfulness meditation, and hypnosis both utilize trance phenomena to help produce focalization and specific improvements in skin disorders through psycho-neuro-endocrine-immunologic mechanisms. Hypnosis, cognitive hypnotherapy, focused meditation, and mindfulness meditation are discussed with respect to improving various skin disorders including acne, acne excoriée, alopecia areata, atopic dermatitis, congenital ichthyosiform erythroderma, dyshidrotic dermatitis, erythema nodosum, erythromelalgia, furuncles, glossodynia, herpes simplex, hyperhidrosis, ichthyosis vulgaris, lichen planus, neurodermatitis, nummular dermatitis, postherpetic neuralgia, prurigo nodularis, pruritus, psoriasis, rosacea, trichotillomania, urticaria, verruca vulgaris, and vitiligo. Their integration into mindfulness-based cognitive hypnotherapy is then discussed and illustrated with improvement in a patient with systemic lupus erythematosus.

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

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.

Use of hypnosis, meditation, and biofeedback in dermatology.

Hypnosis utilizes trance to access otherwise inaccessible repressed or unconscious memories and features of the psyche and control of physiology not attainable in the ordinary conscious waking state. Medical uses of hypnosis in dermatology include reducing discomfort from itching or skin pain, altering ingrained dysfunctional habits such as scratching, promoting healing of skin disorders, searching for psychosomatic aspects of skin disorders and alleviating them, and reframing cognitive and emotional dysfunctional patterns related to skin disorders. Meditation uses trance to center and balance. Medical uses of meditation in dermatology include relaxation to promote healing of skin disorders and refocusing with respect to the meaning and emotional negative valance of skin disorders. Biofeedback in dermatology employs instrumentation with visual or auditory feedback to permit conscious awareness and alteration of physiologic phenomena such as sweating as measured by galvanic skin resistance and skin temperature measured by temperature detecting devices, promoting relaxation and healing. These methods and techniques permit access to and intervention in otherwise inaccessible areas that can influence skin disorders. With proper use, they are very safe, with minimal, if any, side effects and sometimes produce significant results where other methods have failed.

Complementary psychocutaneous therapies in dermatology.

The skin and the nervous system develop side by side in the fetus and remain intimately interconnected and interactive throughout life. Because of the skin-nervous system interactions, there is a significant psychosomatic or behavioral component to many dermatologic conditions. This permits complementary nonpharmacologic psychotherapeutic interventions, such as acupuncture, aromatherapy, biofeedback, cognitive-behavioral therapy, hypnosis, placebo, and suggestion, to have positive impacts on many dermatologic diseases. Complementary pharmacologic psychotherapeutic interventions, such as herbs and supplements, also may help improve some dermatologic disorders.

Herbal therapy in dermatology.

Herbal therapy is becoming increasingly popular among patients and physicians. Many herbal preparations are marketed to the public for various ailments including those of the skin. Herbal therapies have been used successfully in treating dermatologic disorders for thousands of years in Europe and Asia. In Germany, a regulatory commission oversees herbal preparations and recommended uses. In Asia, herbal treatments that have been used for centuries are now being studied scientifically. Currently, the United States does not regulate herbal products, as they are considered dietary supplements. Therefore, there is no standardization of active ingredients, purity, or concentration. There are also no regulations governing which herbs can be marketed for various ailments. This has made learning about and using these treatments challenging. Information compiled in a practical fashion may enable more patients to benefit from these treatments currently used worldwide. We reviewed the herbal medications that show scientific evidence of clinical efficacy, as well as the more common herbs shown to be useful in the treatment of dermatologic disorders. The safety of each herb has been addressed to better enable the physician to know which herbal therapies they may want to begin to use in practice. Common drug interactions and side effects of herbal medicines that may be seen in the dermatologic setting were also studied.

Using hypnosis to facilitate resolution of psychogenic excoriations in acne excoriée.

Hypnotic suggestion successfully alleviated the behavioral picking aspect of acne excoriée des juenes filles in a pregnant woman who had been picking at the acne lesions on her face for 15 years. Acne excoriée is a subset of psychogenic or neurotic excoriation. Conventional topical antibiotic treatment was used to treat the acne. Compared with other treatments for uncomplicated acne excoriée, hypnosis is relatively brief and cost-effective and is non-toxic in pregnancy.

Hypnosis-facilitated relaxation using self-guided imagery during dermatologic procedures.

Many patients experience some degree of anxiety and/or discomfort during dermatologic procedures. For most patients this anxiety or discomfort is tolerable, but a few find it intolerable to the point of interference with the accomplishment of the procedure. A case is presented in which a 51 -year-old female experienced so much anxiety that it jeopardized the continuation of a necessary procedure. When (with her consent) a trance state was induced through hypnosis, she relaxed and remained in a pleasant mental condition for the remainder of the procedure. This case illustrates the usefulness of hypnosis in selected situations where it can alleviate anxiety and discomfort associated with dermatologic procedures. Suggested trance induction, maintenance, and termination scripts are included to assist those with adequate training and experience in providing this comfort to selected patients through hypnosis.