[Skin-picking disorder]. / Skin-Picking-Syndrom.

The disorder is characterized by compulsive repetitive skin-picking (SP), resulting in skin lesions. The patients must have undertaken several attempts to reduce or stop SP. The disorder must have led to clinically significant limitations in social, professional, or other important areas of life. The symptoms cannot be better explained by another emotional disorder or any other dermatological disease. In the new DSM-V, skin-picking disorder has been included in the diagnostic system as an independent disorder and describes the self-injury of the skin by picking or scratching with an underlying emotional disorder. SP is classified among the impulse-control disorders and is, thus, differentiated from compulsive disorders as such. There are often emotional comorbidities. In cases of pronounced psychosocial limitation, interdisciplinary cooperation with a psychotherapist and/or psychiatrist is indicated.

[Somatoform pruritus: a psychosomatic disease model]. / Somtoformer Pruritus in der hautärztlichen Praxis: Wie kann ein psychosomatisch orientiertes Krankheitsmodell integriert werden?

Pruritus is an interdisciplinary symptom that is difficult to diagnose and treat. When there is no evidence of an organic cause, it is challenge for both the patient and the doctor. Itching affecting non-inflamed and otherwise normal skin is often classified as somatoform pruritus. When treated in an interdisciplinary manner with psychosomatic specialists, the patient increasingly becomes aware of still-unrecognized inner-emotional conflicts. At the same time, however, it must be taken into account that the pruritus may precede an underlying disease by a long time and that the diagnosis must be checked regularly. Basic psychosomatic competence and experience in the administration of psychopharmaceuticals is recommended for dermatologists. Taking a psychosomatic concept of disease into account may improve patient satisfaction and compliance, and help to avoid doctor-hopping.

[Psychosomatic dermatology]. / Psychosomatik in der Dermatologie.

Psychosomatic dermatology deals with skin disorders that are substantially influenced by psychosocial causes, sequelae or circumstances or in which these are important in the selection of therapy for the particular patient. In this context, skin diseases have been recognized in a biopsychosocial model for holistic medicine. In a wider sense, psychosomatic dermatology embraces every aspect of intra- and interpersonal problems relating to skin disorders and psychosomatic trigger mechanisms and/or ways of coping with skin disorders. A distinction is made between primarily psychic conflicts, psychosomatic diseases and somatopsychic aspects. Approaches to treatment take account of the doctor (doctor's-assistant)-patient relationship, compliance factors, the dermatosis patient's quality of life and the psychosocial health of the dermatologist, and also steps that can be implemented in the context of the practice management and basic psychosomatic treatment including referral for special psychotherapy.

Reduced expression of nicotinic alpha subunits 3, 7, 9 and 10 in lesional and nonlesional atopic dermatitis skin but enhanced expression of alpha subunits 3 and 5 in mast cells.

BACKGROUND: The skin cholinergic signalling system is modulated in atopic dermatitis (AD). OBJECTIVES: To investigate of the role of nicotinic acetylcholine receptors (nAChRs) in the pathogenesis of AD. METHODS: We investigated the expression and localization of nAChR alpha subunits in AD by quantitative reverse transcription-polymerase chain reaction and immunohistochemistry of biopsies from lesional and nonlesional areas of AD skin and of skin biopsies from healthy control persons. RESULTS: Our data demonstrate the presence of mRNA and protein of the nAChR alpha subunits 3, 5, 7, 9 and 10 in keratinocytes and mast cells in healthy and AD skin. Expression of the alpha subunits 3, 7, 9 and 10 was generally reduced in the skin of patients with AD whereas mast cells in AD but not in healthy skin showed alpha3 and alpha5 subunit immunoreactivity. Differences in the subunit mRNA levels between lesional and nonlesional skin were obtained for the alpha subunits 3, 9 and 10 with higher levels of alpha3 but lower levels of alpha10 subunit mRNA in lesional areas. No differences in the expression of the alpha subunits was found between the groups of extrinsic, intrinsic or mixed AD types, between genders and between smokers and nonsmokers. CONCLUSIONS: This supports the idea that the cholinergic system is dysregulated independently from inflammation in AD and that inflammation further modulates individual nAChR subunits.

[Atopic dermatitis and stress? How do emotions come into skin?]. / Neurodermitis und Stress. Wie kommen Gefühle in die Haut?

It is widely accepted, that stress can induce or exacerbate atopic dermatitis. The physiological mechanisms that mediate this negative influence of stress on atopic dermatitis are not clearly understood. This topic has been actively investigated in recent years focusing on neuroimmunological, psychoendocrinological studies and examination of integrity and function of skin barrier under stress. Different neuropeptides and neurotrophins seem to play an important role in stress-induced neurogenic inflammation and connection of nervous and immune system. Mast cells play a key role in the development of inflammatory reaction to stress. Skin barrier is altered by stress by means of increased cortisol level. Thereby lamellar body secretion is decreased and epidermal expression of antimicrobial peptides (beta-defensin and cathelicidin) is down-regulated. We review recent investigations in this field.

[Suicidal behavior in dermatology]. / Suizidalität in der Dermatologie.

Even in dermatology one can potentially encounter suicidal patients. A risk of suicide can be preexisting, appear as complication of skin disorders or be triggered by medications such as interferons. Patients at risk must be specifically asked about suicidal ideations and tendencies. Acute suicide risk requires immediate crisis intervention. In dermatology suicide risk has been described in severe acne conglobata (especially men) and metastatic melanoma. Patients with chronic or potentially fatal disease or severe pain may be suicidal. In addition patients with depression, alcohol dependency, substance abuse, schizophrenia or borderline personality disorder are at special risk. We review psychodermatological diseases with risk of suicide and point out treatment strategies. More attention should be focused on the early recognition of a possible risk of suicide in dermatology patients.

Clinical pictures and classification of somatoform disorders in dermatology.

Somatoform disorders in dermatology are a heterogeneous group from a biopsychosocial point of view. Among the clinical patterns we find, for example, pruritus, pain, paresthesia as well as feelings of disfiguration, eco-syndromes, erythrophobia or psychogenic pseudoeffluvium. The multiple clinical symptoms are usually accompanied by psychosocial disorders, these are subjective complaints by the patient which cannot be medically objectified. The relevant somatoform disorders in dermatology can be differentiated as somatisation disorders, hypochondriacal disorders, somatoform autonomous disorders, persistent somatoform pain disorders and "other somatoform disorders". A precise differential-diagnostic division is necessary in order to initiate adequate therapy strategies. With this overview article, we would like to make an updated classification recommendation for dermatology and present experiences in therapy.

Atopic dermatitis -- topical therapy: do patients apply much too little?

BACKGROUND: The treatment of atopic dermatitis still remains a challenge. Little research has been done on the issue of the extent to which patients correctly use prescribed topical preparations under everyday conditions. AIMS: To investigate what quantity of topical preparations is applied by outpatients in daily routine treatment over a 26-week period and to what extent this consumption is related to the course of the severity of patients' skin conditions. METHODS: Thirty adult outpatients (20 female and 10 male) with atopic dermatitis were examined at four different times during 26 weeks. For treatment and skin care these patients were given a topical glucocorticoid preparation (prednicarbate) and the corresponding emollient. RESULTS: The average severity rating (SCORAD) was 29.6 (before therapy 33.9, after 26 weeks 27.4). The SCORAD indices improved by a mean of 6.5 points (p<0.05). CONCLUSION: Patients who applied the correct amount of the prednicarbate-containing preparations (not less than 90% of 0.5 g/dm(2)) to the areas of affected skin showed a significant improvement in SCORAD indices across the four measuring times.

[Prevalence of psychosomatic disorders in dermatologic patients. Experiences in 2 dermatology clinics with a liaison therapy model]. / Prävalenz psychosomatischer Charakteristika in der Dermatologie Erfahrungen mit Liaisonmodellen an 2 Hautkliniken.

INTRODUCTION: The prevalences and differences of biopsychosocial disorders were investigated in the dermatologic clinics of Erfurt and Giessen, where a liaison-therapy model has been established. Different dermatological diseases were compared by a variety of psychological tests, and patients with the same diagnosis were compared between the two clinics. PATIENTS AND METHODS: We examined 406 patients for psychosomatic problems with diagnostic interviews and psychometric tests. The coping of skin disease questionnaire (CSD) and the Symptom Checklist (SCL-90R) served as diagnostic measures. Between 1995-2000, 71 patients were seen in Erfurt and 335 in Giessen. The distribution of skin diseases and the psychosomatic disorders are shown by ICD-10 diagnoses. RESULTS: The comparison of an East and a West German city showed no significant differences in the whole group or the parallel groups using the CSD and SCL-90R. There was only a tendency to a greater reduction of quality of life in Erfurt. Patients with glossodynia evaluated themselves in all psychometric tests as very "normal". By contrast, patients suffering from alopecia and acne felt very helpless and seemed to have a need of greater psychosocial care. CONCLUSIONS: The biopsychosocial characteristics of the patients treated in the dermato-psychosomatic units in Erfurt and Giessen show no significant differences. Patients with diseases such as alopecia and acne are underestimated in regard to the need for additional psychosocial care. The liaison therapy model is an effective approach to diagnose psychosomatic-dermatological disorders and decide if further psychosomatic treatment is indicated.

Psychological factors associated with hand dermatoses: which subgroup needs additional psychological care?

BACKGROUND: The aetiology of hand dermatoses (HD) is very heterogeneous. Psychological influences on severity and coping in hand eczema have been only rarely investigated. OBJECTIVES: To investigate whether psychological factors correlate with somatic factors, in order to be able to estimate the possible need for psychosocial treatment of these patients. METHODS: In a cross-sectional study 101 hand dermatosis patients (49F, 52M) with psoriasis (n = 26), vesicular hand eczema (n = 33) or contact dermatitis (n = 42) were examined with regard to dermatological [diagnosis, severity, Erlanger Atopy Score (EAS)], allergic (patch test) and psychological aspects [Coping with Chronic Skin Diseases questionnaire (CSD), Allover Depression Scale (ADS), Social Readjustment Rating Scale (SRRS), questionnaire for measuring Factors of Aggression (FAF)],and Visual Analogue Scales (VAS) concerning itching, scratching and impairment. Subgroups of high stress responders (high-SR) vs. low stress responders (low-SR) were also examined. RESULTS: Of the patients with HD, 47.52% are convinced that 'stress' influences the course of their disease. Analysis of variance shows that the subjective reaction to stress (high-SR) correlates with higher severity scores, more itching, higher depression scores and more life events. High-SRs were younger and the onset of the disease was earlier compared with patients without a subjective reaction to stress (low-SR). In the CSD those with especially high-SR but negative patch-test results stated significantly higher values for itching, helplessness and search for information. CONCLUSIONS: Psychological factors should be taken into consideration in the treatment of patients with HD. High-SR patients with a negative patch-test seem to require more adjuvant psychological care.

The "Dorian Gray Syndrome": psychodynamic need for hair growth restorers and other "fountains of youth.".

The psychic-dynamic factors underlying the hypochondriac disorder involving an obsessive preoccupation with physical attractiveness (dysmorphophobia) and the treatment possibilities for some manifestations of this syndrome have been examined. This psychosomatic illness frequently leads to the taking of finasteride, a medication that halts the balding process in cases of androgenetic alopecia or even stimulates renewed hair growth. The nosological demarcation of the disorder requires the differential diagnosis of depressive, hypochondriac and delusionary disorders. The psychodynamics involved, as deduced from 2 case studies, takes the form of an expansion of the patients' reductionist perspective, characterized by an emphasis on external types extending to a psychogenetic attitude with regression into narcissistic fixation. The authors seek eternal youth which is a "leitmotif' of the disorder, and they apply the term "Dorian Gray Syndrome" after Oscar Wilde's novel. The treatment recommended is a course of intensive psychotherapy; often the topic of "life-style medication" must be introduced before the specific narcissistic conflicts behind the current symptoms can be treated.

[Psychosomatic dermatology in Germany: a survey of 69 dermatologic clinics]. / Psychosomatische Dermatologie in Deutschland. Eine Umfrage an 69 Hautkliniken.

BACKGROUND AND OBJECTIVE: A questionnaire study of German dermatological clinics was designed to show the situation and development of psychosomatic dermatology 10 years after a similar study. PATIENTS/METHODS: A questionnaire was sent to 170 dermatological clinics. 76 were send back; 69 of them (40.6%) were evaluable. The questionnaires were mostly answered by the heads of the dermatological clinics (38/69 = 55.1%). RESULTS: Nearly 85% of the dermatological clinics answered that they take psychosomatic aspects into consideration in the therapy. 5.1% of the dermatologists working in clinics have additional psychotherapeutic certification. The improvement of coping behaviour seems to be the main goal of psychosomatic interventions. The importance of psychic factors increased in the last 10 years in comparison to a former study in regard to most of the dermatological diseases. CONCLUSIONS: Psychosomatic aspects seem to be an obligatory part of inpatient dermatological therapy. The frequency of some diseases was underestimated in comparison with results from literature.

Aggressive verbal behaviour as a function of experimentally induced anger in persons with psoriasis.

The importance of psychosocial factors on the etiology and fluctuating disease activity of psoriasis has been discussed in recent years. The present experiment investigated whether psoriatics in an anger-inducing situation show less aggressive verbal behaviour than average person. Twenty-six psoriatics and 26 matched healthy controls were randomly assigned to either an anger-inducing or a non-anger-inducing social situation. The experimental conditions were arranged so that the persons were confronted with either negative, derogatory, or positive, favorable feedback on eight characteristics (intelligence, appearance, maturity, tolerance, honesty, friendliness, humor, and helpfulness). Standardized feedback was given by a confederate of the experimenter. Immediately after the feedback was received by the subjects the photo hand test (PHT) was applied. The PHT is an item-analyzed, validated projective test for aggression. Two independent raters categorized the subjects' responses into six mutually exclusive categories, including a category for responses with aggressive content. 2 x 2 analysis of variance (psoriatics vs controls; anger-induced vs non-anger induced) were calculated for the aggressive responses and the acting-out score (AOS). The results showed a significant interaction, suggesting that psoriatics did indeed exhibit fewer verbal aggression responses under anger-inducing circumstances than the controls.

[From neuropeptides and cytokines to psychotherapy. Skin diseases between psychoneuroimmunology research and psychosomatic treatment]. / Von Neuropeptiden und Zytokinen zur Psychotherapie. Hauterkrankungen zwischen psychoneuroimmunologischer Forschung und psychosomatischer Therpie.

Most therapists recognize that emotional factors influence the course of neurodermitis (ND). Most studies concerning the influence of experimental, acute stressors brought only inconsistent results in ND. Most likely, the experimental stressors chosen thus far were only able to poorly simulate the reactions to real stressors in neurodermitis patients. More recent articles, however, were able to demonstrate changes in psychoimmunological parameters under experimental stress conditions in ND in comparison with a control group of persons with healthy skin. Retrospective studies, serial analyses over time and psychotherapeutic evaluation studies were able to demonstrate even more clearly that emotional factors influence the course of ND.

Coping with acne vulgaris. Evaluation of the chronic skin disorder questionnaire in patients with acne.

The present study investigated how patients with acne vulgaris cope with their disease. By means of questionnaires, relations and interactions between acne and psyche were evaluated. In addition to the evaluation of a specific questionnaire for patients with chronic skin disorders (CSD), assessing psychosocial impairment by the disease, depression and social anxiety were investigated in patients with acne. The study included 50 patients with acne. The CSD showed significant correlations with Beck's depression inventory, the interaction-anxiety questionnaire and the health locus of control scale. The CSD revealed significant differences compared to a control group of 33 patients with healthy skin. Furthermore the patients' attitudes towards triggering factors and disease-related limitations in everyday life are presented. The results of the study demonstrate that patients with acne suffer from emotional distress and psychosocial problems caused by their disease; however, impairment is not correlated with the objective severity of acne.

[Skin disease and sexuality. An empirical study of sex behavior or patients with psoriasis vulgaris and neurodermatitis in comparison with skin-healthy probands]. / Hautkrankheit und Sexualität. Eine empirische Studie zum Sexualverhalten von Patienten mit Psoriasis vulgaris und Neurodermitis im Vergleich mit Hautgesunden.

Fifty-three patients with psoriasis, 24 patients with atopic eczema and 52 controls with healthy skin were compared with regard to their sexual behavior. For the test, questionnaires developed by Arentewicz as well as our own questionnaire on sexuality and partnership were used. Patients with skin diseases had a significantly impaired sex life, compared to those with healthy skin. There was a highly significant reduction in the exchange of tenderness in patients of both sexes, and in the capacity for orgasm in female patients. On the other hand, no significant difference was found concerning the frequency of intercourse. Patients with psoriasis felt more impaired than those with atopic eczema. Ninety-three percent of psoriatics and 96% of patients with atopic eczema had not been asked about their sexual life by their attending doctor. We discuss to what extent skin diseases are possibly involved in the regulation of nearness and distance among partners. The dermatologist should a be knowledgeable and understanding source for patients which skin diseases who have questions about their disease and its effect on their sex life.