More than a skin disease: stress, depression, anxiety levels, and serum neurotrophins in lichen simplex chronicus

Abstract Background: Lichen simplex chronicus is a dermatological condition due to excessive scratching, with few studies on psychoneuroimmunology. Objective: We aimed to estimate the levels of stress, depression, and anxiety, and to measure serum levels of neurotrophins in patients with lichen simplex chronicus, and to correlate these parameters with the severity of the disease and pruritus. Methods: Thirty-six patients with lichen simplex chronicus and 36 age- and sex-matched healthy controls were included. Each participant was administered the Hospital Anxiety and Depression Scale and Perceived Stress Scale questionnaires, along with a visual analog scale for pruritus. Levels of neurotrophins (brain-derived neurotrophic factor, neurotrophin-3, nerve growth factor, glial cell line-derived neurotrophic factor) were determined by ELISA assays. Results: The scores of Perceived Stress Scale-10, Hospital Anxiety and Depression Scale were statistically higher in patients (p < 0.05 for all). The serum levels of all neurotrophins were significantly lower in patients compared to healthy controls (p < 0.05 for all). Disease severity showed no correlation with all four neurotrophins. In linear regression models applied for increased visual analog scale-pruritus scores and disease severity these two variables were statistically significant predictors (p = 0.043). Study limitations: A direct causal relationship was not addressed. Conclusion: Lichen simplex chronicus patients are at risk of increased levels of stress, anxiety, depression, and present decreased levels of neurotrophins, that may suggest a role in the pathophysiology of this disorder.

Psicodermatología: una introducción a sus conceptos, nosología y modelos de abordaje / Psychodermatology: An introduction to its concepts, nosology and approach models

Es imposible separar la enfermedad física de la enfermedad mental, puesto que la fisiopatología de cualquier enfermedad contiene a la esfera psicológica dentro de sus múltiples elementos. En ese sentido, muchas especialidades médicas pueden reclamar su relación con la Psiquiatría, puesto que son innumerables las enfermedades que tienen nexo con signos y síntomas psiquiátricos (por ejemplo, la enfermedad inflamatoria intestinal en Gastroenterología; el asma bronquial en Neumología, entre otras). No obstante, con la Dermatología la relación es mucho más evidente. La Psicodermatología es una especialidad que surge de la conjunción de dos ramas aparentemente divergentes de la Medicina: la Psiquiatría y la Dermatología. En Psicodermatología, algunos pacientes presentan enfermedades principalmente dermatológicas con comorbilidades psicosociales secundarias, mientras que otros tienen trastornos psiquiátricos primarios con sintomatología cutánea significativa. Así también, debido a que varias enfermedades dermatológicas no solo se acompañan frecuentemente de dolor e incomodidad, sino que son inmediatamente visibles para los demás, las personas afectadas por estas condiciones pueden sufrir consecuencias sociales y emocionales. Con base en lo anterior, este artículo de revisión presenta los conceptos, nosología y modelos de abordaje de esta ciencia médica, haciendo hincapié que, debido a la interacción permanente entre la mente y la piel, se hace necesario que el paciente sea tratado como una unidad constituida por varios niveles, incluyendo aspectos cutáneos, emocionales y mentales.

It is impossible to separate the physical illness from the mental illness, since the pathophysiology of any disease contains the psychological sphere within its multiple elements. In this sense, many medical specialties can claim their relationship with Psychiatry, since there are innumerable diseases that have a link with psychiatric signs and symptoms (for example, inflammatory bowel disease in Gastroenterology; bronchial asthma in Pneumology, among others). However, with Dermatology the relationship is much more evident. Psychodermatology is a specialty that arises from the conjunction of two apparently divergent branches of Medicine: Psychiatry and Dermatology. In Psychodermatology, some patients present mainly dermatological diseases with secondary psychosocial comorbidities, while others have primary psychiatric disorders with significant cutaneous symptoms. Also, because various dermatologic diseases are not only frequently accompanied by pain and discomfort, but are immediately visible to others, people affected from these conditions can suffer social and emotional consequences. Based on the above, this review article presents the concepts, nosology, and approach models of this medical science, emphasizing that due to the permanent interaction between the mind and the skin, it is necessary for the patient to be treated as an unit made up of several levels, including cutaneous, emotional and mental aspects.

Psicodermatología: la necesidad de comprender la mente y el cuerpo como una unidad indivisible / Psychodermatology: the need to understand mind and body as an indivisible unit

La influencia entre la mente y el cuerpo es innegable, la psicodermatología es una subespecialidad de la dermatología, que trata el estudio de las condiciones que presentan un gran solapamiento entre la patología dermatológica y psiquiátrica, principalmente, en casos en los cuales hay eventos psicológicos predominantes al inicio de las dermatosis o en los casos en que estas producen daño o un efecto desequilibrante en la psiquis. OBJETIVO: Realizar una revisión de la literatura disponible acerca del desarrollo y avances en el campo de la psicodermatología. Existen diferentes y verosímiles explicaciones acerca de cómo surge la interrelación entre la piel y la mente, que comienzan en su origen embrionario común en el ectodermo, mostrando sincronía con algunos ritmos biológicos, pero por sobre todo, el impacto bidireccional que existe con el estrés. Estas dermatosis se han agrupado en tres categorías distintas: condiciones psiquiátricas primarias, condiciones psiquiátricas secundarias y trastornos psicofisiológicos de la piel. CONCLUSIONES: La psicodermatología busca dar atención a los estados mentales y emocionales que son parte de un contexto mayor, donde la piel es uno de los principales afectados. A la fecha, la investigación aún es incipiente, sin embargo, parece claro que se requiere una formación integral de los diferentes profesionales que se ven enfrentados a estas condiciones en sus pacientes, que les permitan, sino curar, proporcionar recursos para lidiar con los problemas de una manera balanceada y autónoma.

The connection between mind and body is undeniable, psychodermatology is a subspecialty of dermatology, which deals with the study of the conditions that present a great overlap between dermatological and psychiatric pathology, mainly in cases in which there are psychological factors predominant at the beginning of the dermatoses, or in cases where these produce damage or an unbalancing effect in the psyche.OBJECTIVE: To carryout a review of the available literature on development and advances in the field of psychodermatology. There are different and plausible explanations about how the interrelation between the skin and the mind arises, which begin in their common embryonic origin in the ectoderm, showing synchronicity with some biological rhythms, but, above all, the bidirectional impact of stress. These dermatoses have been grouped into three distinct categories: primary psychiatric conditions, secondary psychiatric conditions, and psychophysiological skin disorders.CONCLUSIONS: Psychodermatology seeks to give attention to the mental and emotional states that are part of a larger context, where the skin is one of the main affected organs. To date, the research is still incipient, however, it seems clear that it requires a comprehensive training of different professionals who are faced with these conditions in their patients, that allow them, if not to cure, to provide resources to deal with the problems in a balanced and autonomous way.

The Psychological Burden of Chronic Dermatological Diseases

The psychological burden of skin diseases should not be ignored as it can potentially affect the overall disability experienced by the patient. The relationship between skin diseases and psychiatric illness is bidirectional and is manifested as cause as well as effect. Dermatological disorders like acne, alopecia areata, psoriasis and vitiligo often have a severe form that causes disability and exclusion from a normal life .Psychiatric disorders like stress, anxiety and depression are seen to be instrumental in development and progression of dermatological diseases and this study is to ascertain the association between depression and anxiety with various dermatological diseases. Methods: A total of 100 patients, visiting the Out Patient Department of Dermatology, who are referred to Department of Psychiatry for the evaluation of Psychiatric symptom, were included in the study after obtaining written informed consent. Psychiatric morbidities were screened using Brief Psychiatric Rating Scale (BPRS), Hamilton Depression Rating Scale (HAM-D) and Hamilton Anxiety Rating Scale (HAM-A). Results: The present study envisaged to explore a relationship between chronic dermatological diseases and psychiatric morbidities. Prevalence of psychiatric comorbidities was maximum in psoriasis (75%) followed by urticaria and Acne Vulgaris(65% each), Alopecia Areata(60%) and Vitiligo (50%). Depression with anxiety disorder (27%) followed by moderate depression with anxiety disorder (23%), anxiety disorder (10%) and severe depression with anxiety disorder (3%) were the most common psychiatric comorbidity. Conclusion: The present study was carried out to evaluate the prevalence of psychiatric morbidities among patients with different dermatological illnesses. The growing relationship between skin and psychiatry has given birth to a new branch of medicine, i.e. psychodermatology, which marks the mutual relationship and interaction between psychiatry and dermatology.

Psychodermatology: An Association of Primary Psychiatric Disorders With Skin / Psicodermatología: asociación de trastornos psiquiátricos primarios con la piel

ABSTRACT 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.

RESUMEN La asociación del sistema nervioso con la piel está bien documentada. Muchos trastornos psiquiátricos comunes pueden implicar a la piel directa o indirectamente. Se encontró asociación de 13 trastornos psiquiátricos primarios que llevan a enfermedades dermatológicas, y de las 13, asociación de 2 consideradas idiopáticas. La asociación entre la mente y el cuerpo se ha estudiado durante mucho tiempo. Varios problemas de la piel conducen a los síntomas psicológicos y psiquiátricos, pero no todos los problemas llevan a síntomas psiquiátricos de la piel. Por el contrario, parece que muchas enfermedades psiquiátricas primarias se asocian con trastornos de la piel.

A pele que somos e a pele que sentimos: Pele - símbolo - consciência / The skin we are, the skin we feel: Skin - symbol - consciousness / La piel que somos y la piel que sentimos: Piel - símbolo - conciencia

O sistema somatosensorial humano funciona de forma dinâmica. Nossos órgãos recebem e produzem estímulos que são convertidos em informação biológica, necessária para a formação, maturação e funcionamento global do nosso corpo, mente e espírito. O "sentir-se bem, sentir-se com saúde" é uma consequência de vários fenômenos biológicos que envolvem o sistema nervoso central. Neste contexto, serão abordados os papéis da pele, do tato e do toque no desenvolvimento e estruturação da consciência e do que se chama "pele simbólica" ou "pele psíquica".

The human somatosensory system works in a dynamic way. Our organs receive and produce stimuli that will be converted into biological information, which are necessary for formation, maturation and the overall functioning of the body, mind, and spirit. The "wellbeing sensation" is a result of several biological phenomena that involve the central nervous system. In this context, the role of skin, tact and touch in the development and structuring of our consciousness will be discussed. The concepts of "symbolic skin" and "psychic skin" will be explored.

El sistema somatosensorial humano funciona de forma dinámica. Nuestros órganos reciben y producen estímulos que se convierten en información biológica, necesaria para la formación, maduración y funcionamiento global de nuestro cuerpo, mente y espíritu. El "sentirse bien, sentirse con salud" es una consecuencia de varios fenómenos biológicos que involucran el sistema nervioso central. En este contexto, se abordarán el papel de la piel, del tacto y del toque en el desarrollo y estructuración de la conciencia y de lo que se llama "piel simbólica" o "piel psíquica".

Pro-inflammatory Cytokines, Biomarkers, Genetics and the Immune System: A Mechanistic Approach of Depression and Psoriasis / Citocinas proinflamatorias, biomarcadores, genética y sistema inmunológico: un enfoque mecanicista de la depresión y la psoriasis

ABSTRACT Objective: To highlight the inflammatory and immunological mechanisms involved in depression and psoriasis. Methods: A comprehensive literature search was performed in various databases, in total 145 studies were selected. Results: Depression and psoriasis have an association. Immune mechanisms -the actions of tumor necrosis factor-a, interleukin 1 (IL-1), IL-2, IL-10, IL-22, IL-17, interferon-7, IL-1ß, prostaglandin E2, C-reactive protein, IL-6, and IL-8 etc.-, and some genetic changes are involved. Conclusions: A possible bidirectional relationship of psoriasis and major depression exists; i.e. the depression leads to psoriasis, and psoriasis leads to depression. We recommend more studies in the future to get a deeper and better understanding about this relationship.

RESUMEN Objetivo: Poner de relieve los mecanismos inflamatorios e inmunológicos involucrados en la depresión y la psoriasis. Métodos: Se realizó en varias bases de datos una búsqueda bibliográfica completa; en total se incluyeron 145 estudios. Resultados: Hay asociación entre depresión y psoriasis y están involucrados mecanismos inmunitarios -las acciones del factor de necrosis tumoral alfa, las interleucinas (IL) 1, 2, 10, 22 y 17, el interferón gamma, la IL-1ß, la prostaglandina E2, la proteína C reactiva, la IL-6 y la IL-8, etc. - y algunos cambios genéticos. Conclusiones: Hay una posible relación bidireccional entre psoriasis y depresión, es decir, la depresión lleva a psoriasis y la psoriasis lleva a depresión. Se recomiendan más estudios en el futuro para obtener una comprensión más profunda y mejor sobre esta relación.

Vitiligo as a psychosocial disease: apprehensions of patients imprinted by the white / O vitiligo como uma doença psicossocial: apreensões de pacientes marcados pelo branco / El vitíligo como una enfermedad psicosocial: comprensión de pacientes marcados por lo blanco

This study aimed to show the comprehension that patients bearing vitiligo have over their condition, also assessing the association with their health and disease concepts. It is a qualitative research with descriptive and exploratory purposes, carried out from an epidemiological survey throughout the years of 2010-2013, with records from a dermatology outpatient care sector of a seminal hospital located in the city of Campina Grande - Paraíba, Brazil. It was identified that from the 832 existing records, 13 were of vitiligo patients and, from them, eight agreed to be part of this study, answering a semi-structured questionnaire. Data examination was made using the Thematic Content Analysis technique, identifying four categories. Results indicated that the process of being stricken with the disease is directly related to social practices that target the "stained" subject, over whom vitiligo has imprinted its patches.(AU)

O presente estudo teve por objetivo apresentar a compreensão de sujeitos portadores de vitiligo sobre sua afecção, avaliando também a associação com a concepção de saúde-doença. Trata-se de uma pesquisa qualitativa de caráter descritivo e exploratório, realizada a partir de um levantamento epidemiológico do período de 2010-2013, em prontuários do ambulatório de dermatologia de um hospital de referência localizado na cidade de Campina Grande - Paraíba, Brasil. Identificou-se que de 832 prontuários existentes, 13 pacientes possuíam vitiligo e, destes, apenas oito aceitaram participar do estudo, respondendo a um questionário semiestruturado. O tratamento dos dados ocorreu por meio da técnica de análise de conteúdo temática, identificando quatro categorias. Os resultados indicaram que o processo de adoecimento está diretamente ligado às práticas sociais que são direcionadas ao sujeito "manchado", sobre o qual o vitiligo imprimiu suas marcas.(AU)

El objetivo de este estudio fue presentar la comprensión de sujetos portadores de vitíligo sobre su afección, evaluando también la asociación con el concepto de salud-enfermedad. Se trata de una investigación cualitativa de carácter descriptivo y exploratorio, realizada a partir de un levantamiento epidemiológico del período de 2010-2013, en fichas del ambulatorio de dermatología de un hospital de referencia localizado en la ciudad de Campina Grande - estado de Paraíba, Brasil. Se identificó que, de las 832 fichas existentes, 13 pacientes sufrían de vitíligo y de ellos solamente ocho aceptaron participar en el estudio, respondiendo un cuestionario semi-estructurado. El tratamiento de los datos se realizó por medio de la técnica de análisis de contenido temático, identificando cuatro categorías. Los resultados indicaron que el proceso de enfermedad está directamente vinculado a las prácticas sociales que se dirigen al sujeto "manchado", sobre el cual el vitíligo imprimió sus marcas.(AU)

Review of Psychiatric Adolescent Inpatient with Dermatologic Consultations / 정신신체의학

OBJECTIVES: To review the patterns of the dermatologic consultations of psychiatric adolescent inpatient and to explore the relationship between the dermatologic disorders and psychiatric disorders. METHODS: We retrospectively studied the data from 22 cases referred by psychiatric adolescent for a dermatologic consultation over 10 years in Daegu Catholic University Medical Center and compared with the data from 108 cases referred by the other department adolescent patients. RESULTS: The mean age of patients was 15.9. The male to female ratio was 1:1.44. The most common psychiatric and dermatologic disorder was major depressive disorder and acne, respectively. The most frequent reason for consultation was to ask for dermatologic disease or condition(54.5%) followed by to perform cosmetic procedure of patients need(40.9%) and to perform dermatologic test(4.6%). CONCLUSIONS: More than just a cosmetic disfigurement, dermatologic disorders are associated with a variety of psychopathologic problems that can affect the patient. Increased understanding of biopsychosocial approaches and liaison among psychiatrists and dermatologists could be beneficial.

Lesiones en la piel por auto-injuria / Self-Cutting lesions of the skin

En el sector de Psicodermatología, del Servicio de Dermatología del Hospital Ignacio Pirovano, tomamos como base fundamental de nuestro trabajo la relación médico-paciente. Es por ello, que consideramos la sujetividad de cada paciente que nos consulta y establecemos un vínculo interpersonal, en el que una de las personas (el paciente) busca recibir ayuda, conocimientos y cuidados, mientras que la otra (el médico) ofrece al paciente sus conocimientos y cuidados acordes a su patología. En algunos casos, esta forma de trabajar se vuelve no solo útil, sino esencial, por ejemplo: cuando se presentan pacientes con lesiones por auto-injuria, como la que se presentó en el centro de salud en la provincia de Buenos Aires, donde una de las autoras (GO) se desempeña como médica de guardia, además de pertenecer a nuestro Servicio de Dermatología. La auto-injuria se define como un acto deliberado y repetitivo que persigue dañar el propio cuerpo sin intención suicida, siendo los métodos más frecuentes los cortes, golpes y quemaduras¹. Este trastorno es conocido también como: autodaño, lesiones auto-inflingidas o auto-mutilación (self-injury, self-harm, self cutting). Este trastorno que se expresa en la piel, tal como observamos en la paciente adolescente que presentamos, debe mantenernos atentos a los médicos dermatólogos, generalistas y aquellos que trabajen en servicios de guardia, dado que estamos ante un trastorno psiquiátrico cada vez más frecuente entre los jóvenes, para poder lograr la derivación a Salud Mental y un adecuado tratamiento, según la patología psiquiátrica subyacente.

In the section of Psychodermatology, in the Dermatology Service of I. Pirovano Hospital, we look at the physician-patient relationship as the fundamental base of our work. We consider the subjectivity of each patient complain as an interpersonal bond in which one of the persons (the patient) seeks help, knowledge and care, while the other (the physician) offers his expertise accordingly. In some cases, this way of working results useful and essential. For example, when patients appear with self-injury, such as the one introduced by Dr. Gabriela Oliveira in the health center in which she works (besides belonging to our Dermatology Department), in the province of Buenos Aires. Self-injury is defined as a deliberate and repetitive act which seeks to harm one’s body, without suicidal intention. Cutting, hiting and burning are the most common methods and the disorder is also known as self-harm or self-cutting. This condition is expressed in the skin, as we will observe in the adolescent patient presented, must be vigilant to dermatologists, general practitioners and those working in call duty doctors, given that this is an increasingly common psychiatric disorder among young people to achieve mental health referral and appropriate treatment, according to the underlying psychiatric disease.

Psychodermatology: A comprehensive review.

Psychodermatology is an interesting domain of dermatology that overlaps with psychiatry. This arena in dermatology has received limited diligence, partly due to lack of training in this realm. We present here a comprehensive review of salient features and treatment updates in primary psychiatric dermatoses and have also discussed the role of psyche in psychophysiological cutaneous disorders. Secondary psychiatric morbidity is relatively common among patients visiting the dermatologists but often overlooked and uncared for. Dermatologist should be able to initiate basic pharmacotherapy, should be knowledgeable about various non-pharmacological treatments and know the right time to refer the patient to the psychiatrist. Awareness and pertinent treatment of psychodermatological disorders among dermatologists will lead to a more holistic treatment approach and better prognosis in this unique group of patients.

Nuestra experiencia en el servicio de dermatología del Hospital General de Agudos Dr. I. Pirovano / Our experience in the dermatology department of the General Acute´s Hospital Dr. I. Pirovano

En este trabajo se presenta cómo funciona el sector de psicodermatología, en el servicio de dermatología de nuestro hospital. El objetivo principal de esta práctica, apunta a crear un puente entre las afecciones de la piel y los padecimientos emocionales, para tratar al paciente en forma integral. Toda nuestra experiencia está basada y apoyada, en la importancia que tiene para nosotros supla relación médico paciente.

In this article it is presented how the psychodermatology section works, in the dermatology department of our hospital. The main objective of this practice aims to build a bridge between skin affections and emotional sufferings, in order to treat the patient in an integral way. All our experience is based and supported on the importance that the doctor-patient relationship has for us.

Abordagem multiprofissional na visão integral do paciente com vitiligo / Multidisciplinary approach in the patient's integral vision with vitiligo

A psicodermatologia é uma área que estuda e integra o trabalho de médicos e psicólogos, objetivando um melhor entendimento das doenças cutâneas. O vitiligo, caracterizado por máculas acrômicas, é causado por destruição adquirida de melanócitos, sendo associado com fatores emocionais. Há três teorias para explicar a destruição dos melanócitos no vitiligo: a imunológica, a citotóxica e a neural. Independentemente da origem, existe a percepção nítida da sua relação com aspectos emocionais. O aparecimento e o alastramento da doença cursam com o aumento das frustrações e preocupações. Vários doentes relatam o aparecimento após traumas emocionais significativos. Quanto maior a área corporal afetada, maior o nível de estresse, depressão e tensão emocional. Provavalmente, alterações emocionais desequilibram o organismo, favorecendo alterações hormanais e imunológicas, podendo desencadear e piorar o vitiligo. A pessoa deve ser vista com um todo, constituída de outras dimensões, como a psíquica, social, econômica e cultural. Este trabalho objetiva demonstrar a visão de homem integral, considerando as influências biopsicossociais e aimportância do trabalho multiprofissional.

Tha Psychodermatology is an area that studies and integrate the doctor's work, psychologists, looking for a better understanding of skin diseases. The vitiligo, marked by achromatic maculates, is caused because there is an adquire destruction of melanocytes, so related with emotional components. There are three theories that explain the destruction of the melanocytes in vitiligo: an immunological response, one that is citolitic and the last one, neural. Causes apart, that is a clear perception about the relation with emotional aspects. The beginning and spreading of the disease courses with frustrations and concerns, both always increasing. A lot of sick people relates the beginning of the disease after some important emotional stress. The higher is the body area affected, higher is the leval of stress, depression and emotional tension. Probably, emotional changing unbalance the organism, favoring hormonal and immunological changes, and it may trigger de vitiligo. The person must be seen as a whole person, consists of other dimensions, such as psychological, social, economic and cultural. This work shows the integral vision of man, considering the influences biopsychosocial and the importance of multidisciplinary working.

A integração mente e corpo em psicodermatologia / An integration mind and body in psychodermatology

Percebemos hoje um incremento dos estudos que envolvem a integração entre os aspectos médicos e psicológicos, ou seja, entre as questões do corpo e do psíquico. Dessa forma, esse artigo se propõe a revisar os achados teóricos relacionados à Psicodermatologia, permitindo ainda uma reflexão crítica a respeito do tema e de seus novos rumos. Sabe-se que a Psicodermatologia é o ramo que se dedica ao estudo e tratamento de problemas dermatológicos que são causados e/ou influenciados por fatores psicológicos. As ligações que existem com o sistema nervoso tornam a pele altamente sensível a emoções, independente da nossa consciência. Assim, a pele, muitas vezes, expressa os nossos sentimentos mesmo quando não estamos cientes deles. Fica-nos, então, a idéia de que ao falarmos de doenças de pele devemos considerar o ser humano como um ser integrado, no qual aspectos sociais, biológicos e psicológicos interagem constantemente.

Nowadays there has been an increase in the studies which involve the integration between medical and psychological aspects, that is, between body and psyche subjects. In this way this article aims at revising the theoretical findings related to Psychodermatology, allowing a critical reflection concerning to the subject and its possible new directions. We know that Psychodermatology is a branch which aims at the study and treatment of dermatologic problems which are caused ad/or influence by psychological factors. The links which exist with the nervous system make the skin highly sensitive to emotions regardless of our conscience. Therefore the skin, many times, expresses our feelings even when we are not aware of them. So, the idea that remains is that when we talk about skin diseases we should consider the human being integrally. Social, biological and psychological aspects are constantly interacting.