Effects of a Brief Mindfulness-based Intervention in Patients with Psoriasis: A Randomized Controlled Trial.

Mindfulness is a special type of attention, namely focusing on the current moment in a non-judgmental manner. Extensive mindfulness-based interventions have been shown to have positive effects in patients with psoriasis. However, it is unclear whether brief (2-week) interventions are also beneficial. Therefore, the aim of this study was to investigate the effects of a 2-week mindfulness-based intervention in patients with psoriasis. Patients were randomly assigned to an experimental (treatment-as-usual + mindfulness-based intervention) or control group (treatment-as-usual) during their clinic stay. All variables were measured by self-report using validated questionnaires: primary outcomes were mindfulness and self-compassion, secondary outcomes were itch catastrophizing, social anxiety, stress and skin status. Variables were assessed prior to, immediately and 3 months after the intervention. Effects were tested by repeated-measures analysis of variance (ANOVA). Analyses of pre-post-measurements (n = 39) revealed a significant interaction effect on self-reported mindfulness [F(1,35) = 7.46, p = 0.010, η2p = 0.18] and a tendency to a significant effect on self-reported self-compassion [F(1,36) = 3.03, p = 0.090, η2p = 0.08]. There were no other significant effects, but most descriptive data were in favour of the experimental group. However, the control group showed a greater improvement in skin status. Further studies are needed to replicate these findings and investigate which subgroups especially profit from such an intervention.

White paper on psychodermatology in Europe: A position paper from the EADV Psychodermatology Task Force and the European Society for Dermatology and Psychiatry (ESDaP).

Psychodermatology is a subspecialty of dermatology that is of increasing interest to dermatologists and patients. The case for the provision of at least regional psychodermatology services across Europe is robust. Psychodermatology services have been shown to have better, quicker and more cost-efficient clinical outcomes for patients with psychodermatological conditions. Despite this, psychodermatology services are not uniformly available across Europe. In fact many countries have yet to establish dedicated psychodermatology services. In other countries psychodermatology services are in development. Even in countries where psychodermatolgy units have been established, the services are not available across the whole country. This is especially true for the provision of paediatric psychodermatology services. Also whilst most states across Europe are keen to develop psychodermatology services, the rate at which this development is being implemented is very slow. Our paper maps the current provision of psychodermatology services across Europe and indicates that there is still very much more work to be done in order to develop the comprehensive psychodermatology services across Europe, which are so crucial for our patients.

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.

Is stress related to itch in German students? Results of an online survey.

Introduction: German students report to be more stressed than the general population. Highly stressed students from other countries (United States, Australia, Saudi-Arabia) were found to have more skin symptoms, including itch, than lowly stressed students. The current study aimed to assess whether itch is associated with stress in a larger sample of German students. Methods: 838 students (3.2% of all invited students) took part in the questionnaire based study and filled in the Perceived Stress Questionnaire as well as a modified version of the Self-Reported Skin Questionnaire. Students were categorized into highly (HSS) and lowly stressed students (LSS) by determination of the 25th and 75th percentile. Results: Itch occurred significantly more often in HSS compared to LSS (OR = 3.41 (2.17-5.35)). In addition, itch intensity was significantly related to perceived stress. Discussion: These findings not only highlight the importance of offering stress management trainings also to students in Germany in order to minimize itch, but also encourage future research on stress and itch in certain student subgroups.

Study protocol: Neuro-inflammatory parameters as mediators of the relationship between social anxiety and itch intensity: A cross-sectional, controlled laboratory study in patients with psoriasis and healthy skin controls.

INTRODUCTION: Psoriasis (PSO) is a disease that in the majority of patients is accompanied by itch, which imposes a great burden and positively relates to anxiety. Social anxiety, a facet of anxiety associated with social withdrawal, may be a predictor of itch intensity in this patient group. Moreover, anxiety is linked to the secretion of neuroendocrine and inflammatory parameters such as substance P (SP), interleukin (IL)-6 and IL-17, which are also related to itch. In this research project, we investigate first, whether there is a direct relationship between social anxiety and itch intensity in patients with PSO and second whether the secretion of SP, IL-6 and IL-17 in the skin mediates this relationship. Additionally, PSO-patients are compared to healthy skin controls regarding their level of social anxiety, itch intensity and the secretion of SP, IL-6 and IL-17. METHODS AND ANALYSES: For study 1, we aim to recruit 250 psoriasis patients and 250 healthy skin controls who complete questionnaires to assess social anxiety, itch intensity and control variables (e.g. sociodemographic variables and severity of PSO). A linear hierarchic regression will be used to determine whether social anxiety significantly contributes to itch intensity. In study 2, we plan to apply the suction blister method to 128 patients and healthy skin controls recruited from study 1 to determine SP, IL-6 and IL-17 in tissue fluid extracted from the skin. A mediation analysis will be conducted using the SPSS-macro PROCESS to test whether the relationship between social anxiety and itch is mediated by SP, IL-6 and IL-17. TRIAL REGISTRATION NUMBERS: DRKS00023621 (study 1) and DRKS00023622 (study 2).

Perceived stress in patients with inflammatory and non-inflammatory skin conditions. An observational controlled study among 255 Norwegian dermatological outpatients.

Background: Inflammation may increase stress, while stress may promote inflammation. Most dermatological conditions are chronic and inflammatory, while some, such as cancer, naevi and tumours are non-inflammatory, but may cause stress because of the fear of malignancy and the necessity for surgical and other invasive treatments. Stress among patients with skin diseases is little explored. Objectives: To assess perceived stress in patients with inflammatory and non-inflammatory skin conditions compared to healthy controls. Methods: Observational cross-sectional study. Consecutive outpatients (N = 255) visiting the Department of Dermatology, Stavanger University Hospital, Norway and 148 skin-healthy controls contributed by answering questionnaires on sociodemographics, stressful life events, economic difficulties, self-rated health and perceived stress. The validated Perceived Stress Scale10 was used to evaluate stress. A dermatologist examined patients and registered their diagnoses and comorbidities. Controls included in this study were not examined by a dermatologist and self-reported their comorbidities. Results: Patients with an inflammatory skin disease or psoriasis have a tripled risk of reporting moderate to high stress compared with controls when adjusted for relevant confounders, including having experienced a stressful life event recently or having a comorbidity. Patients with a purely non-inflammatory skin disease perceived stress no differently than controls. Conclusion: Patients with inflammatory skin disease perceived higher stress than controls and patients with non-inflammatory skin conditions. Dermatologists may play a role in awareness of the importance of stress in skin disease.

S2k guideline: Diagnosis and treatment of chronic pruritus.

Pruritus is a cross-disciplinary leading symptom of numerous diseases and represents an interdisciplinary diagnostic and therapeutic challenge. In contrast to acute pruritus, chronic pruritus (CP) is a symptom of various diseases that is usually difficult to treat. Scratching and the development of scratch-associated skin lesions can alter the original skin status. In the presence of an itch-scratch-cycle, even secondary diseases such as chronic prurigo can develop. Chronic pruritus leads to considerable subjective suffering of those affected, which can result in restrictions on the health-related quality of life such as sleep disturbances, anxiety, depressiveness, experience of stigmatization and/or social withdrawal up to clinically relevant psychic comorbidities. Medical care of patients should therefore include (a) interdisciplinary diagnosis and therapy of the triggering underlying disease, (b) therapy of the secondary symptoms of pruritus (dermatological therapy, sleep promotion, in the case of an accompanying or underlying psychological or psychosomatic disease an appropriate psychological-psychotherapeutic treatment) and (c) symptomatic antipruritic therapy. The aim of this interdisciplinary guideline is to define and standardize the therapeutic procedure as well as the interdisciplinary diagnosis of CP. This is the short version of the updated S2k-guideline for chronic pruritus. The long version can be found at www.awmf.org.

Prevalence and Increase over Time of Twelve Self-reported Skin Symptoms: Data from Two Representative Samples from 1998 and 2015.

Point prevalence estimates for common skin symptoms vary widely. Most research has focussed on a few symptoms and a single point of observation. The aim of this study is to determine point prevalence rates for 12 self-reported skin symptoms in 1998 and 2015 and to assess changes in the reporting of skin symptoms over time. Symptoms were assessed by 2 national face-to-face household surveys of representative samples of the German general population (n1998=2,079, n2015=2,511). Point prevalence ranges were 6.8-26.2% in 1998 and 11.6-32.1% in 2015. Dandruff, body odour, pimples, and an itchy scalp were the 4 most common skin symptoms, each of which affected more than 20% of the population at both time-points. For almost all symptoms, a statistically significant increase, with very small to small effect sizes, was observed over time. The increase in skin symptoms over time is congruent with the increase in skin diseases reported by the Global Burden of Disease study.

Exploring the EQ-5D Dimension of Pain/Discomfort in Dermatology Outpatients from a Multicentre Study in 13 European Countries.

Pain and discomfort are important symptoms in dermatology. The aim of this cross-sectional, multicentre study was to describe the prevalence of pain/discomfort and its associations in patients with several dermatological conditions across 13 European countries. The outcome was the prevalence of pain/discomfort according to a question of the EQ-5D questionnaire. Data collected from November 2011 to February 2013 were complete for 3,509 consecutive outpatients. Moderate or extreme pain/discomfort was reported by 55.5% of patients and 31.5% of controls with no skin conditions. The highest proportions were reported by patients with hidradenitis suppurativa (92.9%), leg ulcer (81.4%), prurigo (80%) and lichen planus (75.6%). Pain/discomfort was associated with older age, low educational level, clinical severity, flare on scalp or hands, itch, depression, anxiety, low quality of life, and thoughts of suicide. It is important to enquire specifically about pain/discomfort during clinical consultations and to address it when planning a patient's care.

Development and psychometrics of the English version of the Itch Cognitions Questionnaire.

BACKGROUND: The aim of this study was to validate the English version of the Itch Cognition Questionnaire in a sample of patients with chronic itch due to psoriasis or atopic dermatitis. An English-language version of an instrument assessing itch-related cognitions is needed since cognitions can contribute to a worsening of itch, and chronic itch is prevalent in English-speaking counties and internationally. METHODS: The German Itch Cognitions Questionnaire was translated into English, and cognitive interviewing was conducted to finalize item wording. Internal and test-retest reliability, item discrimination, responsiveness to change, and construct, convergent, and discriminant validity were assessed in a national sample of 137 individuals with chronic itch due to atopic dermatitis or psoriasis recruited online. RESULTS: Internal reliability was high with Cronbach's alphas of 0.93 for the Catastrophizing subscale and 0.88-0.90 for Coping. The Pearson's correlation assessing 1-month test-retest reliability for the Catastrophizing subscale was r = 0.62 and for the Coping subscale was r = 0.61. The corrected item-total correlation revealed that items were relatively consistent with the scores for the subscales (with correlations ranging from 0.58 to 0.79), indicating very good item discrimination. Results of factor analysis, convergent and discriminant, and responsiveness to change analyses provided evidence for validity. CONCLUSIONS: This study showed good psychometric characteristics of the English version of the Itch Cognitions Questionnaire. We suggest that future studies investigate the use of the measure in clinical practice to assist with treatment planning and outcome assessment related to itch as well as address study limitations such as sampling and replication.

Prevalence of Pruritus in a Single Cohort of Long-term Kidney Transplant Recipients.

is missing (Short communication).

Psychosocial Aspects of Adult Acne: Data from 13 European Countries.

The link between acne and psychiatric morbidities has been demonstrated in many studies; however, large scale studies aiming to reveal the psychosocial impact of acne are rare. The aim of this study was to assess the psychological burden of adult acne patients. This analysis was based on a multicenter study including 213 acne patients and 213 controls from 13 European countries. The Hospital Anxiety and Depression Scale (HADS), Dermatology Life Quality Index, and EuroQol 5 dimensions 3 levels scores of the patients with acne were analyzed. Patients with acne (n = 213) had higher HADS scores for anxiety (mean ± standard deviation 6.70 ± 3.84) and depression (3.91 ± 3.43) than the controls (p < 0.001 for both). For patients with acne, 40.6% reported that they were very concerned about their skin disease, 12.3% had suicidal ideation, and, among those, 10 (4%) patients implied that acne was the cause of their suicidal thoughts. After adjusting for other variables, patients who had suicidal ideation (p = 0.007, and adjusted odds ratio 3.32 [95% confidence interval (CI): 1.39-7.93]) and stressful life events (p < 0.001, and adjusted OR 5.85 [95% CI: 2.65-12.86]) had a greater chance of fulfilling the HADS criteria for anxiety. This study highlights the need for a psychotherapeutic approach in order to recognize the concerns of acne patients and optimize their treatment.

Itch and Mental Health in Dermatological Patients across Europe: A Cross-Sectional Study in 13 Countries.

Itch is a highly prevalent and multidimensional symptom. We aimed to analyze the association between itch and mental health in dermatological patients. This multicenter study is observational and cross-sectional and was conducted in dermatological clinics across 13 European countries. A total of 3,530 patients and 1,094 healthy controls were included. Patients were examined clinically. Outcome measures were itch (presence, chronicity, and intensity), the Hospital Anxiety and Depression Scale, EQ-5D visual analogue scale, sociodemographics, suicidal ideation, and stress (negative life events and economic difficulties). Ethical approval was obtained. Results showed significant association between the presence of itch in patients and clinical depression (odds ratio, 1.53; 95% confidence interval, 1.15-2.02), suicidal ideation (odds ratio, 1.27; 95% confidence interval, 1.01-1.60), and economic difficulties (odds ratio, 1.24; 95% confidence interval, 1.10-1.50). The mean score of reported generic health status assessed by the EQ-5D visual analogue scale was 65.9 (standard deviation = 20.1) in patients with itch, compared with 74.7 (standard deviation = 18.0) in patients without itch (P < 0.001) and 74.9 (standard deviation = 15.7) in controls with itch compared with 82.9 (standard deviation = 15.6) in controls without itch (P < 0.001). Itch contributes substantially to the psychological disease burden in dermatological patients, and the management of patients should include access to multidisciplinary care.

Occurrence, Chronicity and Intensity of Itch in a Clinical Consecutive Sample of Patients with Skin Diseases: A Multi-centre Study in 13 European Countries.

Itch is an unpleasant symptom, affecting many dermatological patients. Studies investigating the occurrence and intensity of itch in dermatological patients often focus on a single skin disease and omit a control group with healthy skin. The aim of this multi-centre study was to assess the occurrence, chronicity and intensity (visual analogue scale 0-10) of itch in patients with different skin diseases and healthy-skin controls. Out of 3,530 dermatological patients, 54.3% reported itch (mean ± standard deviation itch intensity 5.5 ± 2.5), while out of 1,094 healthy-skin controls 8% had itch (3.6 ± 2.3). Chronic itch was reported by 36.9% of the patients and 4.7% of the healthy-skin controls. Itch was most frequent (occurrence rates higher than 80%) in patients with unclassified pruritus, prurigo and related conditions, atopic dermatitis and hand eczema. However, many patients with psychodermatological conditions and naevi also reported itch (occurrence rates higher than 19%).

Stigmatisation and body image impairment in dermatological patients: protocol for an observational multicentre study in 16 European countries.

INTRODUCTION: Patients with common skin diseases may have substantial psychosocial comorbidity and reduced quality of life. This study aims at exploring further the psychosocial burden of skin diseases by assessing stigmatisation and body image problems in a large sample of patients with skin disease across Europe. METHODS AND ANALYSIS: The study is an observational cross-sectional multicentre study across 16 European countries comparing stigmatisation and body image in patients with skin disease compared with controls. Consecutive patients will be recruited in outpatient clinics and will complete validated questionnaires prior to clinical examination by a dermatologist at each recruitment site. In addition to sociodemographic background information, the outcomes will be: mood disorders assessed by short versions of the Patient Health Questionnaire and the General Anxiety Disorder Assessment; general health assessed by the EuroQol-Visual Analogue Scale; stigmatisation experience assessed by the Perceived Stigmatisation Questionnaire; stress assessed by the Perceived Stress Scale and body image assessed by the Dysmorphic Concern Questionnaire. The main criteria for eligibility are to be 18 years old or more. The analysis will include comparison between patients and controls for the main outcomes using t-tests, analyses of covariance and multivariate logistic regression models adjusting for potential confounding factors. ETHICS AND DISSEMINATION: The study protocol is approved by the University of Giessen and by the local Ethical Committee in each recruitment centre. Informed consent will be given by each participant. The results of the study will be disseminated by publications in international peer-reviewed journals and presented at international conferences and general public conferences. Results will influence support intervention and management of patients with skin disease across Europe. TRIAL REGISTRATION NUMBER: DRKS00012745; Pre-results.

Experiences with the first eczema school in the United States.

Patient education programs are beneficial in the treatment of chronic diseases. In Germany, France, and other countries worldwide, educating children, adolescents, and adults plus the parents of children with atopic dermatitis (AD) leads to better coping with the skin disease, as well as to a reduction in the severity of the skin symptoms and signs. The results in Europe led to the idea to also establish an eczema school in the United States. In the style of the German eczema school, an eczema school was founded in 2014 at Temple University, Philadelphia, PA. Since then, a team consisting of a dermatologist, psychologist, nutritionist, and nurse practitioner has offered an eczema school to interested patients with AD and their families three times a year. This patient education program consists of three weekly 2-hour sessions, which address proper skin care, the itch-scratch cycle, healthy nutrition, and the role of stress in AD. The current review summarizes the first experiences with the education program in the United States.

The Role of Therapy in Impairing Quality of Life in Dermatological Patients: A Multinational Study.

Skin disease and its therapy affect health-related quality of life (HRQoL). The aim of this study was to measure the burden caused by dermatological therapy in 3,846 patients from 13 European countries. Adult outpatients completed questionnaires, including the Dermatology Life Quality Index (DLQI), which has a therapy impact question. Therapy issues were reported by a majority of patients with atopic dermatitis (63.4%), psoriasis (60.7%), prurigo (54.4%), hidradenitis suppurativa (54.3%) and blistering conditions (53%). The largest reduction in HRQoL attributable to therapy, as a percentage of total DLQI, adjusted for confounders, was seen in blistering conditions (10.7%), allergic/drug reactions (10.2%), psoriasis (9.9%), vasculitis/immunological ulcers (8.8%), atopic dermatitis (8.7%), and venous leg ulcers (8.5%). In skin cancer, although it had less impact on HRQoL, the reduction due to therapy was 6.8%. Treatment for skin disease contributes considerably to reducing HRQoL: the burden of dermatological treatment should be considered when planning therapy and designing new dermatological therapies.

The psychosocial burden of hand eczema: Data from a European dermatological multicentre study.

BACKGROUND: The essential physical role, visibility and social importance of the hands place a major psychological burden on patients with hand eczema. OBJECTIVES: The aim of this study was to identify the psychological, social and clinical characteristics of patients with hand eczema, in particular the prevalences of depression, anxiety, suicidal ideation, and comorbidities. MATERIALS AND METHODS: Data on patients with hand eczema were analysed from a large European multicentre study conducted with dermatology outpatients from 13 countries. Groups of patients and controls were compared to analyse the psychological burden of hand eczema. RESULTS: Female patients with hand eczema had higher Hospital Anxiety and Depression Scale (HADS) scores for anxiety (n = 86, median = 7.0) than controls (n = 900, median = 5.0, P = .02), and for depression (median = 4.0) than controls (3.0, P < .001). Patients with high suicidal ideation, with low socioeconomic status and who were widowed or divorced were more likely to fulfil the HADS criteria for anxiety [odds ratio (OR) > 1, P = .038, P < .001, and P < .001, respectively]. The median Dermatology Life Quality Index score was 7.0 (n = 68). DISCUSSION: This study identifies a specific psychological burden experienced by hand eczema patients, highlighting the need for focused psychosocial interventions. Physicians in particular should be aware of the need to identify anxiety and depression in female patients.