Introducing Psychodermatology

By Dr Alia Ahmed / 11 Jul 2018

Dr Alia Ahmed outlines psychodermatology and introducing the service in clinic

Psychodermatology is an emerging subspecialty that is geared to considering both the mind and the skin to provide holistic care to patients with dermatological diagnoses.1 Early texts, dating back to Hipprocrates (460-377 BC), recognised the effect of psychological states on the skin. However it was only really in the 1950s that the psychodermatology movement started, under its widely acknowledged founding by Dr Herman Musaph (1915-1992)1 and the first international conference was held in 1987. Recognising patients that may benefit from a psychodermatological approach is important to ensure good clinical outcomes and improve patient experiences. In this article I will discuss what exactly psychodermatology is and how you can introduce it into your own practice.

What is psychodermatology?

Psychodermatology (also known as psychocutaneous medicine) is an umbrella term encompassing conditions that link the brain with the skin. It is an interface subspecialty that combines dermatology, psychology and psychiatry. The effect of the brain on the skin is mediated by the Hypothalamic-Pituitary-Adrenal (HPA) axis, which is activated by stress to up/ dysregulate inflammatory pathways and cellular processes to cause or exacerbate skin disease.2 Patients with psychodermatological diagnoses fall into three main categories:5

  • Primary dermatological disorders caused by or associated with psychiatric comorbidity. For example, patients with psoriasis or eczema that present with secondary psychiatric comorbidities like anxiety or depression secondary psychiatric comorbidities like anxiety or depression
  • Primary psychiatric disorders that present with skin disease. These include delusional infestation, body dysmorphia, obsessive compulsive tendencies (e.g. trichotillomania)
  • Dermatological conditions that require psychosocial support. For example, vitiligo, alopecia, urticarial, rosacea and acne

There is increasing evidence to suggest that patients with dermatological disease have higher levels of psychological and psychiatric comorbidities than controls.3 According to the British Association of Dermatology (BAD), 85% of dermatology patients feel the psychosocial aspects of their skin disease are a major component of their illness, with 17% needing psychological support to cope; this was based on 127 responses from consultant dermatologists.4 Despite this, the number of dedicated psychodermatology services in the UK are falling.5

Incorporating it in clinic

Establishing psychodermatology services within the NHS is difficult due to lack of expertise in the area, as well as higher associated costs of a specialised service. General dermatologists may not be keen to initiate or monitor psychiatric medications, therefore a special interest and further training in this area is often required. This is typically as a subspecialty fellowship in psychodermatology for up to a year, or through working in a specialised clinic on a regular basis. Other training resources include conferences and courses in psychodermatology. Dermatologists with a special interest in the topic can see and manage patients with psychological/ psychiatric comorbidity, and this may involve support from allied services like psychology. On a tertiary level, psychodermatology clinics can be jointly led by a dermatologist and psychiatrist seeing patients together to manage patients holistically.

I believe that psychodermatological conditions are best managed by a dedicated psychodermatology multidisciplinary team (pMDT).5 This typically consists of dermatologists, psychiatrists, and specialist dermatology nurses (who may be trained in forms of psychotherapy, such as habit reversal). In addition, other healthcare professionals can form part of the pMDT to ensure patients are safely monitored in the community setting, for example child and adolescent mental health specialists (CAMHS), paediatricians, social workers, child/vulnerable adult safeguarding teams, and general practitioners/physicians.4 In order to establish a pMDT, access to clinical and social services is required. In the private setting, establishing the community links is just as important.

Psychodermatological recognition in patients

Patients with psychodermatological conditions can present in a multitude of ways. One of the main presentations is body dysmorphic disorder (BDD) which has been covered comprehensively in previous articles in the Aesthetics journal by Dr Anthony Bewley, Dr Dimitre Dimitrov6 and Dr Sangita Singh.7 Other conditions that are common in this category and pertinent to aesthetic dermatology are acne, rosacea, alopecia, and obsessive compulsive tendencies, for example acne excoriee, trichotillomania, and skin picking.

Assessing psychological impact of dermatological disease

The crux of the psychodermatological consultation is to make adequate assessments of both objective and subjective impact of dermatological disease on the psyche of the patient. This assessment can be made using objective measures such as the Dermatology Life Quality Index (DLQI),10 Hospital Anxiety and Depression Scale (HADS),11 Patient Health Questionnaire (PHQ),12 Cutaneous Body Index (CBI).13 These patient-reported outcome measures (PROMs) are increasingly important as this is a chance for patients to provide feedback on how they feel about their skin on a day-to-day basis. Serial measurements across consultations are helpful to assess improvement or deterioration and can be used as a basis for referral to psychodermatology services. There are a number of important questions healthcare professionals should all be asking patients with dermatological diagnoses, particularly if they are chronic. In-depth assessment can help identify psychological/psychiatric morbidity and thus facilitate better care and onward specialist referral. I believe that examples of appropriate questions are:

  • Are you able to concentrate?
  • Is your sleep affected?
  • Do you feel low in mood?
  • Do you feel tearful or anxious?
  • Does your skin stop you doing the things you want to in life?
  • Are your relationships/physical relationships affected by your skin?
  • Is your social life affected by your skin?
  • How do you think your skin is affecting your loved ones?

Conclusion

Dermatological conditions require holistic management, thus assessment of impact on quality of life of patients using either the questions suggested or objective measures is valuable. This can guide the need for specialty referral to psychodermatology services. If psychiatric comorbidities are identified such as depression or anxiety, adequate monitoring and further medical management via psychodermatology may be indicated. By providing a platform for both medical management of cutaneous disease and concurrent psychological assessment and support, psychodermatology services are ideally placed to manage patients who have been significantly affected by their skin. Such holistic services are in demand by both patients and clinicians, and empower both to achieve better clinical outcomes. By acknowledging the adverse effect of skin disease on the mind, it is possible to directly impact the quality of life of our patients. Establishing psychodermatology services is a key target when thinking about promoting patient wellbeing in the dermatology setting, it requires specialist management and adequate training. I believe, these clinician-led services are the new face of dermatology in the 21st century. 

References

  1. Arenas-Guzmán R. Psychodermatology: past, present and future. Open Dermatology Journal. 2011;5:21-7
  2. Kim JE et al. Expression of Hypothalamic-Pituitary-Adrenal Axis in Common Skin Diseases: Evidence of its Association with Stress-related Disease Activity. Acta Derm Venereol 2013; 93: 387-393
  3. Sampogna F et al. Living with psoriasis: prevalence of shame, anger, worry and problems in daily activities and social life. Acta Derm Venereol 2012; 92(3):299-303.
  4. Lowry CL, Shah R, Fleming C et al, Clinical and Experimental Dermatology, A study of service provision in psychocutaneous medicine, 2014
  5. Bewley AP et al. Introduction. In:Bewley AP, Taylor RE, editors. Practical psychodermatology. Oxford:Wiley Blackwell; 2014. p3-11.
  6. Aesthetics journal, Recognising body dysmorphic disorder in aesthetic practice <https://aestheticsjournal.com/feature/ recognising-body-dysmorphic-disorder-in-aesthetic-practice>
  7. Aesthetics journal, The red flag patient <https:// aestheticsjournal.com/feature/the-red-flag-patient>
  8. Cardwell LA et al. Psychological disorders associated with rosacea: analysis of unscripted comments. Journal of Dermatology and Dermatological surgery 2015; 19(2):99-103.
  9. Hazarika N, Archana M. The psychosocial impact of acne vulgaris. Indian Journal of Dermatology 2016; 61(5):515-520.
  10. British Association of Dermatology, Dermatology Life Quality Index <http://www.bad.org.uk/shared/get-file. ashx?id=1653&itemtype=document>
  11. Svri.org, Hospital anxiety depression scale <http://www.svri.org/ sites/default/files/attachments/2016-01-13/HADS.pdf>
  12. Medical Care, Patient Health Questionnaire, https://journals. lww.com/lww-medicalcare/Abstract/2003/11000/The_Patient_ Health_Questionnaire_2__Validity_of_a.8.aspx
  13. National Center for Biotechnology Information, Use of a Cutaneous Body Image (CBI) scale to evaluate self perceptionof body image in acne vulgaris <https://www.ncbi.nlm.nih.gov/ pubmed/25230060> 

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