Psychologic factors in the development of facial dermatoses.

In medical literature, as well as in daily practice, some common facial dermatoses are considered to be influenced or triggered by emotional factors. The main damager is stress, but depression and anxiety may play a role, among other factors. Some patients may experience a vicious cycle: Their facial dermatosis is triggered or worsened by stress, and in turn, the exacerbation itself is a major stressogenic stimulus. It appears that clinical wisdom and experience preceded clinical investigation in this field. Although patients testify that their emotional state may sometimes influence their facial condition, only limited experimental data exist so far, and only a few facial dermatoses were investigated.

Psychologic consequences of facial dermatoses.

The attractiveness of the human body has always been an important issue in the fields of sociology, psychology, and psychiatry and also in the field of dermatology. In psychodermatology, one often discovers how all these fields intermingle to produce elaborate situations and extreme human difficulties. Perfect skin is widely adored in literature, poetry, and biblical texts, as well as in advertisements, movies, and television. Because in most societies the face is the body part that is visible, imperfections of the skin are also visible; therefore, its flawed appearance bears the potential to become a source of misery to some.

Periorbital (eyelid) dermatides.

Physicians in various specialties-and dermatologists in particular-frequently encounter various forms of inflammation of the eyelids and of the anterior surface of the eye. Distinguishing the cause of itchy, painful, red, edematous eyelids is often difficult. Because the uppermost layer of the eyelids is part of the skin that wraps the entire body, almost every skin disease in the textbook can affect the periorbital area as well. In this contribution, we focused on the most common such disorders that require special consideration, as a result of their special appearance, their challenging diagnosis, or the nature of their treatment. We reviewed the key features of several common dermatides that affect the eyelids, such as atopic dermatitis, seborrheic dermatitis, allergic contact dermatitis, airborne contact dermatitis, rosacea, psoriasis, and others. We focused on the special clinical features, causes, and treatments specific to the delicate skin of the eyelids. Because structures of the eye itself (i.e., the conjunctiva, the cornea, the lens, and the retina) may be involved in some of the discussed periorbital skin diseases, we found it useful to add a brief summary of the eyelid complications of those diseases. We then briefly reviewed some acute sight-threatening and even life-threatening infections of the eyelids, although dermatologists are not likely to be the primary care physicians responsible for treating them.

Psychological factors in skin diseases: stress and skin: facts and controversies.

Psychological stress (PS) has long been related to many common skin diseases and conditions, thought to be the cause of their onset or aggravation. Although clinical experience is often in concordance with this notion, apparently scientific proof can sometimes be challenging rather than straight forward. Although many data have been published, it appears that not enough good statistical evidence exists to support them. The difficulty in validating beyond a doubt the stress-skin interactions has rendered some skepticism among physicians. The gap between clinical expertise and problematic clinical research data has led scientists to bypass the need to tackle the question directly by searching the evidence in basic science.

Patch testing: facts and controversies.

The German dermatologist, Josef Jadassohn (1863-1936), first presented the results of his innovative patch-testing technique in 1895. The safety and efficacy of this diagnostic tool has stood the test of time and is still the gold standard for the diagnosis of allergic contact dermatitis (ACD). Since its discovery, much effort has been put into standardization and optimization of allergens, vehicles, and concentrations of patch-test materials; in procedures of its application; and in reading and scoring of test reactions--all contributing to the development of an accurate, reliable, and safe test with a high reproducibility of its results. Even this seemingly carved-in-stone practice, which has been used for nearly 120 years, has been questioned and challenged, engendering debates, disagreements, and controversies, which show no signs of coming to an end. Almost every step of the procedure has provoked discussions and controversies:

Contact dermatitis: facts and controversies.

The history of contact dermatitis (CD) is inseparable from the history of the patch test, and the patch test is inseparable from the pioneer in the field, Josef Jadassohn (1860-1936). Despite the fact that we have been diagnosing, treating, and investigating the condition for more than 100 years, there are still many unsolved questions and controversies, which show no signs of coming to an end in the foreseeable future. This contribution reviews and highlights some of the disagreements and discrepancies associated with CD. For example: • What is the real sensitizer in balsam of Peru, one of the most common allergens, and what, if any, is the value of a low-balsam diet? • Is benzalkonium chloride, which has well-known and undisputed irritant properties, a contact allergen as well? • Is cocamidopropyl betaine (CABP) a common contact allergen and what is the actual sensitizer in CABP allergy the molecule itself, or impurities, or intermediaries in its synthesis? • How can the significant differences in the prevalence of sensitization of formaldehyde (FA, a common cause of contact allergy) between the United States (8%-9%) and Europe (2%-3%) be explained? • What is the relationship between formaldehyde releasers (FRs) allergy and an FA allergy? Should we recommend that FA-allergic patients also avoid FRs, and, if so, to what extent? • What is the true frequency of lanolin allergy? This issue remains enigmatic despite the expenditure of thousands of dollars and the innumerable hours spent investigating this subject. • What is the basis behind the so-called "lanolin paradox"? This label was coined in 1996 and is still a matter of controversy. • Is there such a thing as systemic CD from nickel, and, if so, to what extent? Is there a cross-reactivity or concomitant sensitization between nickel and cobalt?These are some of the controversial problems discussed. We have selected the ones that we consider to be of special interest and importance to the practicing dermatologist.

Abnormal epidermal barrier in the pathogenesis of psoriasis.

Almost 2 decades ago, Williams and Elias suggested a unifying concept for the pathogenesis of disorders of cornification, according to which the integrity of the epidermal barrier and its effective function is an important factor in the regulation of epidermal DNA synthesis. Interference with the barrier integrity or function will result in epidermal hyperplasia and may be the primary event leading to hyperproliferative skin diseases, such as psoriasis. We have analyzed alterations to several structures of the epidermal barrier that might be responsible for barrier dysfunction and thus lead to hyperproliferation of the epidermis in an attempt to repair the barrier and, as a result, might be inducers of psoriasis. There are several convincing reports indicating that inhibiting of epidermal transglutaminase may lead to epidermal hyperproliferation and that this stimulus might trigger psoriasis among genetically predisposed patients. Disturbance of epidermal barrier function caused by derangement of lipid or cholesterol or ceramide synthesis leads to increased DNA synthesis and epidermal hyperplasia and as a result might be an inducer of psoriasis. We could find little evidence to show that defective defense of the epidermis or an abnormal response of it to bacteria plays a role in the pathogenesis of psoriasis. Accumulating data indicate that there is an association of psoriasis and mutations of genes within the epidermal differentiation complex, which are crucial for the development, maturation, cornification, cross-linking, and terminal differentiation of the epidermis, called psoriasis susceptibility locus 4.

Psychological stress and epidermal barrier function.

The skin is the organ that acts as a barrier between the outer and inner environments of the body. It is thus exposed not only to a wide variety of physical, chemical, and thermal insults from the outside world but also to inner endogenous stimuli. Stress, once an abstract psychologic phenomenon, has taken research's center stage in recent years. The "mind-body connection" is now less of an obscure New Age term and more of an elaborate physiologic pathway by which bilateral communication occurs between body and brain. Dermatologists and dermatologic patients have long acknowledged the effect of stress on the skin and its capability to initiate, maintain, or exacerbate several skin diseases. Because disruption of epidermal barrier integrity may be important in the development of some common skin diseases, it is crucial to understand its vulnerability to psychologic stress.

A psychodermatology clinic: the concept, the format, and our observations from Israel.

The connection between the brain and the skin is more than a physiologic fact. Skin conditions can impose great effects on every field in the patients' lives. Reciprocally, skin diseases can be evoked by psychological problems. A psychodermatology clinic is the format that enables dermatology patients to receive a comprehensive approach to their skin condition as well as to the difficulties it imposes on their lives, and vice versa. Although the notion that skin and mind are connected and have bilateral influences that should be addressed is now appreciated, it is surprising that such clinics are not more prevalent. In the literature there are only a few descriptions of such clinics, and even fewer descriptions of their format and their working formulations with their pluses and minuses. In this article, we describe in detail the working formulation of a new psychodermatology clinic in Israel, as well as our therapeutic methods, data, conclusions, and observations after the first 3 years. During a 3-year period, 124 patients were seen in our psychodermatology clinic, presenting with a vast array of dermatologic complaints. One of our major observations was that lack of proper patient-doctor communication resulted in the development of misconceptions about the disease, low compliance, and even long-lasting psychological difficulties. Another important observation was that there is a true need for such a clinic, among patients as well as among their doctors.

[A new psycho-dermatology clinic in Israel: our first year experience].

Psychodermatology involves the interrelationships between the skin and the mind, especially when considering the formation and evolution of certain common skin conditions. It appears that 30-40% of dermatology patients suffer from certain psychological problems as defined by the ICD-10, in a way that influences their disease severity and progression, as well as their quality of Life. Treatment of such cases requires a multi-disciplinary approach and should involve both a dermatologist and a mental health specialist working together In this article, the authors summarize the preliminary experience of the first year of the only psychodermatology clinic in Israel in several decades, work methods and patients' characteristics and preliminary conclusions.

Cutaneous manifestations of pituitary gland diseases.

The pituitary gland is also known as the "master" gland of the endocrine system, because it controls the functions of the other endocrine glands. From its lofty position in the sella turcica it sends signals to the thyroid gland, adrenal glands, ovaries and testes. It modulates the production of a variety of hormones that have dramatic effect on metabolism, blood pressure, sexuality, reproduction, growth, milk production and other vital body functions and therefore are essential for homeostasis. Since changes of the internal environment often mirrors in the skin, this article will focus on the skin changes in pituitary gland diseases. Disorders resulting from excessive secretion of hormones as well as from hormones deficiency of this complex endocrine organ will be reviewed.

Skin care products and subtle data manipulation.

The dermatologists of today need to master the skills to help their patients in choosing skin care products. As physicians and scientists, we are naturally inclined to trust sophisticated and objectively derived data that are published in scientific, peer-reviewed journals and are presented to us in the form of numbers, tables, and graphs. The question that should be asked is whether a product that scored well in sophisticated tests is really superior and more suitable to the needs of our patients? Or, how far can we trust the data in scientific publications? There is no generally accepted methodology for unbiased evaluation of the efficacy and performance of skin care products. There is also no consensus on which test method best reflects the real-life performance of these products. And, most importantly, even the most objective methods and measuring devices can be and often are manipulated to support the claims of superiority of given products. We will show several out of many, many ways of how the study design, protocols, techniques, and end points can legitimately be adapted to the special characteristics of the specific product, emphasizing its advantages.

Drug Rash with eosinophilia and systemic symptoms versus Stevens-Johnson Syndrome--a case that indicates a stumbling block in the current classification.

A 43-year-old man developed a skin eruption characterized by 'macules with blisters' typical to Stevens-Johnson syndrome, as well as erosions of the lips and buccal mucosa, 2 weeks after he had started treatment with lamotrigine. He had a fever (39.6 degrees C), elevated liver enzymes and atypical lymphocytes in the peripheral blood. This undoubtedly reflects a case of Stevens-Johnson syndrome induced by lamotrigine, but it can also fulfill the criteria of anticonvulsant hypersensitivity syndrome or drug rash with eosinophilia and systemic signs. A case that precisely fits the definition of two syndromes that have different characteristics, different treatments and different prognoses indicates that there is a flaw in the classification.

The Blue Peel: how to do it less expensively and faster.

One well accepted and popular method worldwide for trichloroacetic acid peels is the Obagi Blue Peel technique (Obagi Medical Products, Long Beach, CA). The peel solution is prepared by mixing a fixed volume of 30% trichloroacetic acid with the commercially available Blue Peel base. The authors suggest modifications for performing the peeling faster and less expensively: 1) preparing a larger volume of peel solution from each tube of Blue Peel base; 2) using higher concentrations of peel solution to reduce the number of coats necessary for reaching the desired depth of peel; and 3) storing the solution, as there is no need to adhere to the manufacturer's instructions to prepare the solution immediately before conducting the peel procedure to ensure homogeneity of the solution. The prepared solution can be stored at least 1 year.

Itch and scratch: scabies and pediculosis.

Scabies and lice infestations are almost an everyday diagnosis in the dermatology clinics. Along with the unbearable itch, resistance to medication, secondary infection, and the high risk for spreading the parasite to their close contacts, the patients have also to battle with many myths, prejudice, and shames connected to those infestations.