Unmet Needs in Psychodermatology: A Narrative Review.

Psychodermatology, the multidisciplinary field that explores the intricate interplay between the mind and the skin, has gained increasing recognition over the past decade. However, several knowledge gaps and unmet needs persist in the field. The objective of this narrative review was to investigate the unmet needs in the field of psychodermatology as they pertain to medical training, treatment, research, and care access. PubMed was searched from inception through December 2023 to identify articles related to psychodermatology. Findings revealed several unmet needs within the field of psychodermatology. First, there is a need for further investigation into the pathophysiology that links psychological stress to cutaneous disease including the development of novel therapies targeting key neuropeptides. Second, the existing literature focuses primarily on the pharmacologic treatment of body dysmorphic disorder and body-focused repetitive behaviors, as well as delusional parasitosis, for which the first-line agents are selective serotonin reuptake inhibitors and atypical antipsychotics, respectively. However, additional research into the efficacy and safety of the remaining psychotropic medications and the treatment of other common psychocutaneous diseases is required. Finally, there exists a significant gap in knowledge amongst clinicians tasked with treating psychocutaneous diseases. Dermatologists report low rates of training in psychodermatology and discomfort with prescribing psychotropic medications. In conclusion, increasing resources for dermatologist education on psychotropic agent use, development of new drugs targeting stress-induced skin conditions, and research on the psychocutaneous applications of current medications may greatly improve the quality and access of psychodermatology care.

The mind-skin connection: A narrative review exploring the link between inflammatory skin diseases and psychological stress.

Inflammatory skin diseases are known to negatively impact patient psychology, with individuals experiencing higher rates of stress and subsequent diminished quality of life, as well as mental health issues including anxiety and depression. Moreover, increased psychological stress has been found to exacerbate existing inflammatory skin diseases. The association between inflammatory skin diseases and psychological stress is a timely topic, and a framework to better understand the relationship between the two that integrates available literature is needed. In this narrative review article, we discuss potential neurobiological mechanisms behind psychological stress due to inflammatory skin diseases, focusing mainly on proinflammatory cytokines in the circulating system (the brain-gut-skin communications) and the default mode network in the brain. We also discuss potential descending pathways from the brain that lead to aggravation of inflammatory skin diseases due to psychological stress, including the central and peripheral hypothalamic-pituitary-adrenal axes, peripheral nerves and the skin barrier function.

Role of stress in skin diseases: A neuroendocrine-immune interaction view.

Psychological stress is a crucial factor in the development of many skin diseases, and the stigma caused by skin disorders may further increase the psychological burden, forming a vicious cycle of psychological stress leading to skin diseases. Therefore, understanding the relationship between stress and skin diseases is necessary. The skin, as the vital interface with the external environment, possesses its own complex immune system, and the neuroendocrine system plays a central role in the stress response of the body. Stress-induced alterations in the immune system can also disrupt the delicate balance of immune cells and inflammatory mediators in the skin, leading to immune dysregulation and increased susceptibility to various skin diseases. Stress can also affect the skin barrier function, impair wound healing, and promote the release of pro-inflammatory cytokines, thereby exacerbating existing skin diseases such as psoriasis, atopic dermatitis, acne, and urticaria. In the present review, we explored the intricate relationship between stress and skin diseases from a neuroendocrine-immune interaction perspective. We explored the occurrence and development of skin diseases in the context of stress, the stress models for skin diseases, the impact of stress on skin function and diseases, and relevant epidemiological studies and clinical trials. Understanding the relationship between stress and skin diseases from a neuroendocrine-immune interaction perspective provides a comprehensive framework for targeted interventions and new insights into the diagnosis and treatment of skin diseases.

Psychodermatology knowledge, awareness and patterns of practice among Moroccan dermatologists: a national survey study.

We aimed to assess the knowledge, attitudes and patterns of practice of Moroccan dermatologists and their awareness of psychodermatology (PD). A survey questionnaire was distributed to dermatologists and dermatology trainees from May to July 2022. A total of 112 completed surveys were received. Of these, 63.4% were dermatologists and 36.6% were dermatology residents. Of the participants, 72.3% summarized PD as the psychological impact of dermatological conditions and 50.9% reported frequent involvement with PD. Patients with a psychocutaneous condition represented a significant proportion of dermatological consultations (41.1% of dermatologists stated that 10-25% of their consultations were for psychocutaneous conditions). Only 17% felt 'very comfortable' in the management of PD conditions and 56.3% were not confident prescribing psychotropics. A total of 88.4% had never participated in PD training. Moroccan dermatologists lack a full understanding and proper training in PD. We recommend the incorporation of PD curriculum in training programmes and advocate dermatology and psychiatry liaison.

Perceived Stigmatization among Dermatological Outpatients Compared with Controls: An Observational Multicentre Study in 17 European Countries.

Perceived stigmatization places a large psychosocial burden on patients with some skin conditions. Little is known about the experience of stigmatization across a wide range of skin diseases. This observational cross-sectional study aimed to quantify perceived stigmatization and identify its predictors among patients with a broad spectrum of skin diseases across 17 European countries. Self-report questionnaires assessing perceived stigmatization and its potential predictors were completed by 5,487 dermatology outpatients and 2,808 skin-healthy controls. Dermatological diagnosis, severity, and comorbidity were clinician-assessed. Patients experienced higher levels of perceived stigmatization than controls (p < 0.001, d = 0.26); patients with psoriasis, atopic dermatitis, alopecia, and bullous disorders were particularly affected. Multivariate regression analyses showed that perceived stigmatization was related to sociodemographic (lower age, male sex, being single), general health-related (higher body mass index, lower overall health), disease-related (higher clinician-assessed disease severity, presence of itch, longer disease duration), and psychological (greater distress, presence of suicidal ideation, greater body dysmorphic concerns, lower appearance satisfaction) variables. To conclude, perceived stigmatization is common in patients with skin diseases. Factors have been identified that will help clinicians and policymakers to target vulnerable patient groups, offer adequate patient management, and to ultimately develop evidence-based interventions.

Psychodermatology in Lithuania. A survey on knowledge, awareness, and practice patterns in Lithuanian dermatovenereologists.

The aim of this study was to evaluate the knowledge, awareness, and practice patterns of Lithuanian dermatovenereologists regarding psychocutaneous medicine. An online survey questionnaire was distributed to the members of the Lithuanian Association of Dermatovenereologists and to dermatovenereologists through public and private healthcare institutions in Lithuania. The questionnaire consisted of questions related to dermatovenereologists' awareness, knowledge, experience, and training needs regarding psychocutaneous disorders. 50% of respondents reported having a good or excellent understanding and knowledge of psychodermatology, and 42% feel prepared to consult psychodermatology patients. 54% of doctors rated their preparedness to prescribe psychopharmacological treatment as poor. The most frequent diagnoses referred to mental health professionals were dermatitis artefacta, acne excoriée, other self-inflicted dermatoses, trichotillomania, and pruritus. The most common course of action with patients at high risk of suicide or other acute psychiatric condition was trying to provide psychological support during dermatovenereology consultation. The most frequent management tactic for patients with chronic psychological problems was a referral to a psychiatrist. 85% of all respondents would participate in educational events about psychodermatology. 70% expressed interest in events about psychopharmacological treatment in dermatology. Lithuanian dermatovenereologists have a good understanding and knowledge of psychodermatology and are willing to further their education in this field. However, some gaps remain. Many doctors reported feeling poorly prepared to administer psychopharmacological treatment to their patients and there seems to be a lack of formal training in psychodermatology in Lithuania.

Spanish Version of Teenagers' Quality of Life (T-QoL) for Adolescents with Skin Diseases: Translation, Cultural Adaptation and Validation. / [Artículo Traducido] Traducción, adaptación cultural y validación de la versión española del Teenagers' Quality of Life (T-QoL): cuestionario para adolescentes con enfermedades de la piel.

BACKGROUND: Teenagers' Quality of Life (T-QoL) is an age-specific measure to assess QoL of teenagers suffering from different skin diseases. A validated Spanish language version is lacking. We present the translation, cultural adaptation and validation of the T-QoL into Spanish. METHODS: A prospective study with 133 patients (between 12 and 19 years old), attended at the dermatology department of Toledo University Hospital, Spain (September 2019-May 2020), was carried out for the validation study. The International Society for Pharmacoeconomics and Outcomes Research (ISPOR) guidelines were used for the translation and cultural adaptation. We evaluated the convergent validity with the Dermatology Life Quality Index (DLQI), the Children's Dermatology Life Quality Index (CDLQI) and with a Global Question (GQ) on self-assessed disease severity. We also analysed internal consistency and reliability of the T-QoL tool and confirmed its structure with a factor analysis. RESULTS: Global T-QoL scores significantly correlated with the DLQI and the CDLQI (r = 0.75) and with the GQ (r = 0.63). The confirmatory factor analysis showed optimal fit for the bi-factor model and an adequate fit for the correlated three-factor model. Reliability indicators were high (Cronbach's α = 0.89; Guttman's Lambda 6 index = 0.91; Omega ω = 0.91) and test-retest showed a high stability (ICC = 0.85). The results were consistent with those found by the authors of the original test. CONCLUSION: Our Spanish version of the T-QoL tool is valid and reliable to assess QoL of Spanish-speaking adolescents with skin diseases.

"Pick" wisely: An approach to diagnosis and management of pathologic skin picking.

Manipulation of the skin is ubiquitous in most individuals along a spectrum of extent and severity. Skin picking that results in clinically evident changes or scarring to the skin, hair, and nails or significantly impairs intrapsychic, psychosocial, or occupational function is considered pathological picking. Several psychiatric conditions are associated with skin picking, including obsessive-compulsive disorder, body-focused repetitive behaviors, borderline personality disorder, and depressive disorder. It is also associated with pruritus and other dysesthetic disorders. Although pathologic skin picking, also known as excoriation disorder, is a distinct diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (DSM5), this review attempts to further classify the diagnosis into the following 11 picker categories: organic/dysesthetic, obsessive-compulsive, functionally autonomous/habit, anxious/depressed, attention deficit hyperactivity disorder, borderline, narcissistic, body dysmorphic, delusional, guilty, and angry picker. An organized conceptualization of skin picking can guide providers toward a constructive management approach, ultimately increasing the likelihood of successful therapeutic outcomes.

Psychiatric and psychologic aspects of chronic skin diseases.

Chronic skin diseases can substantially affect a patient's physical, psychologic, and social well-being. Physicians may play a critical role in identifying and managing the psychologic sequelae of the most common chronic skin conditions. Acne, atopic dermatitis, psoriasis, vitiligo, alopecia areata, and hidradenitis suppurativa are chronic dermatologic diseases that put patients at high risk for symptoms of depression, anxiety, and decreased quality of life. Both general and disease-specific scales exist to assess the quality of life in patients with chronic skin disease, the most common being the Dermatology Life Quality Index. The general management approach to the patient with chronic skin disease should incorporate acknowledgment and validation of the patient's struggles; patient education on the potential effect of disease and prognosis; medical management of the dermatologic lesions; coaching on stress management; and psychotherapy. Psychotherapies include talk therapy (eg, cognitive behavioral therapy), arousal-reducing therapies (eg, meditation, relaxation), and behavioral therapies (eg, habit reversal therapy). Improved understanding, identification, and management of the psychiatric and psychologic aspects of the most common chronic skin conditions by dermatologists and other health care providers may positively affect patient outcomes.

Quality of life and satisfaction with life in patients with skin diseases.

Individuals with skin disease may experience negative symptoms such as itching and pain, social stigma, and isolation. This cross-sectional study included 378 patients with skin diseases. The Dermatology Quality of Life Index (DLQI) score was found to be higher in individuals with skin disease. A high score indicates an impaired quality of life. Married people than single people, those who are 31 years old and older than those who are 30 years old and younger have higher DLQI scores. And also those who work than those who are unemployed, those who have diseases than those who do not have any other diseases, and those who smoke than those who are non-smokers have higher DLQI scores. In order to increase the quality of life of individuals with skin diseases, it is necessary to detect risky situations as well as symptom control and add psychosocial and psychotherapeutic interventions to the treatment plan.

Adding happiness to complement the Dermatology Quality of Life Index in psoriasis and atopic dermatitis healthcare: a cross-sectional study

Background: The Dermatology Quality of Life Index (DLQI) is the most commonly used quality of life questionnaire in dermatology. Objectives: The aim of this study was to compare the DLQI to measures of wellbeing and general quality of life in patients with chronic inflammatory skin diseases. Materials & Methods: A cross-sectional study among patients with psoriasis and atopic dermatitis was conducted at a hospital in Munich, Germany (12/2017-04/2019). Participants filled in validated scales measuring happiness, quality of life, and DLQI. Results: In 102 patients with chronic inflammatory skin diseases, the DLQI was associated only with physical quality of life and negative emotions, and not psychological quality of life or positive affect. The DLQI alone accounted for 26% of variance in general quality of life. Combining DLQI and happiness accounted for a total of 73% of variance, with both variables contributing to the model. Conclusion: The DLQI alone only partially reflected well-being. Assessing happiness in addition to the widely used DLQI can contribute to a more comprehensive evaluation of well-being.

Psychiatric Consequences of Skin Conditions: Multiple Case Study Analysis with Literature Review.

This review of current literature demonstrates the psychological implications of skin conditions. Skin conditions of varying severity can impact the quality of patients' lives and have psychiatric consequences. This impact provides a need for healthcare providers to consider the psychological implications of one's skin conditions and their effect on quality of life. The psychological challenges that arise from varying skin conditions show the potential need for both dermatological and psychiatric interventions. The following literature review details the psychiatric consequences of skin conditions under various conditions. It first looks at literature highlighting the psychiatric consequences experienced through various age ranges, from adults to adolescents and children. The paper then explores multiple skin conditions and their psychological effect before highlighting some of the interactions that stress has on the skin that could further exacerbate one's condition. Finally, it examines how patients characterize their experience with their skin condition and goes into some clinical case studies of patients with psychological implications as a result of their skin disorder. The paper also highlights the magnitude of dermatologic patients experiencing psychological conditions in conjunction with their skin conditions.

The need for psychological support in routine dermatological care across the UK.

This article presents a patient perspective on the importance of having psychological support for skin conditions available in the dermatological treatment pathway in the UK.

Psychocutaneous Medicine in Iraq: Current Status and Recommendations.

Objective: To evaluate the knowledge and attitudes of Iraqi dermatologists regarding understanding, diagnosing, and treating psychocutaneous disorders.Methods: An online survey questionnaire was randomly distributed among Iraqi dermatologists through Google Forms in August 2020. The dermatologists were asked to provide information on their understanding of psychodermatology, referral patterns, level of comfort in managing psychocutaneous disorders, awareness of community resources, and interest in learning more about psychodermatology.Results: Of 200 distributed questionnaires, 61 were returned. The most common psychocutaneous disorder seen was acne, followed by alopecia areata and vitiligo. About half of the participants reported being neutral about their comfort level in treating psychocutaneous disorders, and approximately half had no formal training in psychodermatology. Almost 60% of participants did not know of any community resources, and three-quarters were willing to seek educational activities on psychodermatology.Conclusions: The study results revealed that Iraqi dermatologists have significant gaps in knowledge, training, and treatment of psychocutaneous disorders. The survey findings reveal the importance of addressing the training needs of young physicians, including dermatologists, psychiatrists, and primary care physicians, in relation to the psychological component of skin diseases.

[Psychodermatology: Foundations for new developments in integrated care]. / Psychodermatologie: Grundlagen für den Aufbruch zu neuen Versorgungsformen.

The burden of a skin disease is easily understood by any observer due to its visibility: psychosocial issues are therefore ubiquitous in dermatology. Current evidence now shows that this relationship is two-way, as psychosocial stress can cause skin disease and its worsening. This interrelationship poses a major challenge.

The Effect of the COVID-19 Pandemic on Stress-related Dermatologic Diseases.

The number and variety of patients admitted to hospitals have changed due to the COVID-19 pandemic. These changes have also affected dermatology clinics. The pandemic has had an adverse effect on the psychology of people by negatively affecting their quality of life. Patients who were admitted to the Bursa City Hospital Dermatology Clinic between July 15, 2020 and October 15, 2020 and from July 15, 2019 to October 15, 2019 were included in this study. The data of patients were gathered retrospectively by reviewing the electronic medical records and International Classification Diseases (ICD-10) codes. Our results showed that, despite the decrease in the total number of applications, a significant increase was observed in the frequency of stress-related dermatological diseases such as psoriasis (P<0.001), urticaria (P<0.001), atopic dermatitis (P<0.001), and seborrheic dermatitis (P=0.035). However, there was no significant change in the rates of alopecia areata, vitiligo, herpes zoster, and lichen simplex chronicus (P>0.05, for all). There was a significant decrease in the telogen effluvium rate during the pandemic (P<0.001). Our study demonstrates that the incidence of certain stress-related dermatologic diseases increased during the COVID-19 pandemic, which may increase awareness of dermatologists on this issue.

Psychological teleconsultations in patients suffering from chronic skin diseases during the COVID-19 era: a service to improve patients' quality of life.

The COVID-19 era represented an important stressful event affecting population in many different ways, with important negative impact on social, working and relational life. Indeed, the home-isolation in addition to the high-level of distress given by fear of infection, has significantly resulted in a large number of psychological-consequences. Moreover, in order to guarantee a continuity of care, different measures have been applied among hospitals such as the implementation of teledermatology services. For these reasons, we implemented at our Dermatological-Clinic psychological video-consultations through our teledermatology-services. Herein we report our experience of 23 psychological-video-consultations, which led to achieve a significant reduction of DLQI (from 4.4 ± 3.9 at baseline to 1.6 ± 2.5 at week-4) in patients suffering from chronic skin conditions during the COVID-19 era.

An analysis of qualitative responses from a UK survey of the psychosocial wellbeing of people with skin conditions and their experiences of accessing psychological support.

BACKGROUND: Skin conditions have a large emotional, psychological and psychiatric impact on the individual. The All-Party Parliamentary Group on Skin (APPGS) commissioned a qualitative survey to further explore this relationship alongside the experiences of those accessing services in relation to these difficulties in the UK. AIM: To examine the experiences of UK individuals living with a skin condition, and their views of seeking and receiving psychological treatment. This survey formed part of the evidence collected in the preparation of the APPGS Mental Health and Skin Disease report. METHODS: A free-text electronic survey was widely distributed by professional bodies and skin-related charities. Responses were analysed using descriptive thematic analysis and descriptive statistics. Data for each question were classified and labelled, leading to the development of a coding frame. Inter-rater reliability was assessed using Cohen kappa statistic. RESULTS: In total, 544 participants (84% female) completed the survey. The majority of respondents had inflammatory skin diseases such as eczema (43%) or psoriasis (33%). The thematic analysis revealed five key themes associated with impact on mood; impact of intimacy; impact on activities of daily living; lack of recognition from others of the impact; and lack of accessible services. CONCLUSION: The survey demonstrates that there is an urgent need to improve both awareness of the impact that skin conditions can have, and for the provision of psychological services to address this impact.

Psychometric characteristics of DLQI-BRA and Skindex-16 to measure the impact of dermatological diseases on quality of life in Brazilian patients.

OBJECTIVE: To compare the psychometric performance of the Dermatology Life Quality Index (DLQI-BRA) and Skindex-16 to assess quality of life (QoL) in Brazilian patients with dermatological diseases. METHODS: This was a cross-sectional study carried out in a dermatology outpatient clinic of the São Paulo State University, with 188 patients with dermatological diseases. QoL was evaluated using the Dermatology Life Quality Index (DLQI-BRA) and Skindex-16. Cronbach's alpha and Intraclass Correlation for Perfect Concordance (ICC) were used to analyse the reliability and temporal stability, respectively. RESULTS: A positive correlation was found between the total Skindex-16 score and DLQI-BRA (0.75). Both instruments showed a significant (p< 0.01) reduction in their scores at the second assessment, demonstrating that they were sensitive in detecting changes in responsiveness in cases where there was a clinical change. Cronbach alpha coefficients for the instruments showed satisfactory performance (>0,7), but Skindex-16 displayed the highest Cronbach alpha (0.94; CI = 0.93-0.95). CONCLUSION: Both instruments tested showed a good psychometric performance assessing QoL in patients with skin dermatoses. The instruments displayed reliability and temporal stability as well as responsiveness.