Perceived deprivation of social touch in psoriasis is associated with greater psychologic morbidity: an index of the stigma experience in dermatologic disorders.

Touch is a powerful medium of social validation. Patients with skin disorders often experience social rejection when people avoid touching them, possibly fearing contagion or filth. We examined the psychologic impact of the stigma experience among 137 patients with moderate to severe psoriasis; 26.3 percent of patients reported that during the previous month they had experienced an episode when "people made a conscious effort not to touch them" because of their psoriasis. The stigmatized group did not have greater psoriasis severity than the non-stigmatized control group. However, in contrast to the non-stigmatized group, the stigmatized group had higher (P = 0.0003) depression scores (in the range for clinical depression, as measured by the Carroll Rating Scale for Depression), by stepwise logistic regression analysis using a wide range of psychopathologic measures as the independent variables. These findings underline the profound impact of the stigma experience in psoriasis, and possibly other dermatologic conditions that are associated with social stigma.

Prevalence and epidemiology of unsuspected onychomycosis in patients visiting dermatologists' offices in Ontario, Canada--a multicenter survey of 2001 patients.

BACKGROUND: Questionnaire studies have been used to determine the prevalence of onychomycosis in the United Kingdom and Europe. One disadvantage of this methodology is that the patient self-diagnoses the onychomycosis. There have been very few large studies involving clinical examination of the nails of subjects, followed by mycological confirmation of the onychomycosis. We therefore determined the prevalence of onychomycosis in patients visiting dermatologists' offices in Ontario, Canada. METHODS: In a prospective, multicenter study, the finger- and toenails of all new patients presenting to dermatologists' offices were examined by a board-certified dermatologist. If there was clinical suspicion of onychomycosis, then nail samples were obtained for mycological examination at a central laboratory. Patients referred specifically for the management of onychomycosis were excluded. RESULTS: Toenails appeared abnormal in 455 (22.7%) of 2001 patients. Mycologically-confirmed pedal onychomycosis was present in 182 (9.1%) of the 2001 patients. The estimated value of the prevalence of onychomycosis in Ontario is 6.86% (95% confidence interval (CI): 5.8-8.0%), when corrected for age and sex of the general population using census data. Onychomycosis increased with age (P < 0.0001). The odds of males having onychomycosis was 84.3% greater than females of the same age (P = 0.0003). The distribution of organisms in the 141 patients with pedal onychomycosis who were culture positive was: dermatophytes 131 (92.9%), Candida species 4 (2.8%) and non-dermatophyte molds 6 (4.3%). CONCLUSIONS: The prevalence of mycologically-confirmed toenail onychomycosis was 9.1%, with the estimated prevalence in Ontario being 6.86%. The majority of patients with abnormal-appearing nails were unaware they might have onychomycosis, that it is infectious and potentially treatable, suggesting that there is potential for increased public awareness and education.

Stress and alopecia areata: a psychodermatologic study.

Psychosocial stress has been reported to play a role in the onset and/or exacerbation of alopecia areata. Little is known about the clinical characteristics of alopecia areata patients whose alopecia is stress-reactive. We examined the relation between the stress reactivity of alopecia areata and a wide range of psychosocial measures among 16 patients with alopecia areata/totalis and 28 patients with alopecia universalis. The degree to which the alopecia was exacerbated by stress was measured by patient ratings on a 10-point scale. A wide range of psychologic measures correlated (p<0.05) with the stress reactivity score. Stepwise logistic regression analysis revealed that patients with higher depression scores were more likely to be in the high-stress reactor group. Patients whose alopecia is stress-reactive may suffer from depressive illness, a potentially important consideration in the overall management of such patients.

A higher prevalence of onychomycosis in psoriatics compared with non-psoriatics: a multicentre study.

There is some controversy about the prevalence of onychomycosis in patients with psoriasis compared to non-psoriatics. We therefore measured the prevalence of toenail onychomycosis in psoriatics and non-psoriatics attending dermatologists' offices. None of the patients had a referring diagnosis of onychomycosis. The prevalence of pedal onychomycosis in psoriatics (n = 561) was 13%. The odds of patients with psoriasis having onychomycosis was 56% greater than non-psoriatics of the same age and sex (P = 0.02). In the psoriatics, when the toenails were clinically abnormal, the prevalence of onychomycosis was 27%. The odds of developing onychomycosis increased with age (P < 0.0001) and the odds of men developing onychomycosis was 2.5 times that of women (P = 0.0001). The duration of psoriasis did not significantly affect the odds of developing onychomycosis. The fungal organisms recovered from psoriasis subjects with onychomycosis were similar to those in the normal population with onychomycosis (P = 0.58).

Early onset (< 40 years age) psoriasis is comorbid with greater psychopathology than late onset psoriasis: a study of 137 patients.

Early onset (< age 40 years) psoriasis has been reported to be more readily triggered by environmental factors such as stress, in contrast to late onset (> or = age 40 years) psoriasis. We examined whether certain psychopathologic factors differentiated the psoriasis patient with early onset versus late onset disease. One hundred and thirty-seven psoriasis inpatients completed a battery of psychosocial questionnaires. Logistics regression analysis, using the psychologic measures, age and TBSA affected as independent variables, revealed that higher Anger-in (Anger Expression Scale) scores significantly (p < 0.05) increased the odds or probability of having early versus late onset psoriasis. Psoriasis with onset prior to age 40 is comorbid with greater difficulties with assertion and expression of anger, a personality trait that may adversely affect the patient's capacity to cope with stress.

The use of high-frequency ultrasound as a method of assessing the severity of a plaque of psoriasis.

BACKGROUND AND DESIGN: Ultrasound imaging, while initially developed to visualize internal organs, is now being applied to image the skin. In this preliminary study, we used a high-frequency, 40-MHz ultrasound imaging system to provide high-resolution images in psoriasis and examined the relationship between clinical and ultrasound ratings in plaque-type psoriasis. The ultrasound image of a psoriatic plaque demonstrates a superficial echogenic band (band A), followed by a nonchogenic band (band B), and a deeper echogenic band (band C). RESULTS: In psoriatic plaques (N = 145), the severity of the psoriasis as assessed according to the degree of scaling, erythema, and thickness (SET score) correlated best with the width of band B (P < .001, r = 0.86) and less well with the width of bands A (P < .001, r = 0.59) and C (P < .001, r = 0.44). For the treated psoriatic plaques (n = 64), for which paired readings were available before and after therapy, changes in the SET scores correlated best with the change in the width of band B (P < .001, r = 0.96) and less well with the change in the width of bands A (P < .001, r = 0.61) and C (P < .001, r = 0.45). Ultrasound analyses and clinical evaluation were performed by independent raters. CONCLUSIONS: The data suggest that high-frequency ultrasound imaging may prove to be a noninvasive technique that can be used as an adjunct to the clinical evaluation of the lesional severity of psoriatic plaques.

High frequency 40-MHz ultrasound. A possible noninvasive method for the assessment of the boundary of basal cell carcinomas.

BACKGROUND: Ultrasound imaging systems operating close to 20 MHz in frequency have been used to image skin tumors. Ultrasound imaging at 20 MHz has been used to determine the boundaries of basal cell carcinomas (BCCs). An inherent shortcoming of imaging systems operating at these frequencies is their limited resolution. OBJECTIVE: We investigated whether 40-MHz ultrasound imaging could provide higher resolution compared with the lower frequency systems and thus be a superior, noninvasive method of assessing the boundaries of BCCs. METHODS: Nine BCCs from six individuals were examined clinically and ultrasonographically, and then biopsied to confirm diagnosis. The depth of BCCs measured on histological sections was compared with the corresponding value obtained using ultrasound. For this study we required a nonsurgical, nondestructive means of treating BCCs that would allow repeated ultrasound imaging, and therefore topical 5-flurouracil (5-FU) was chosen. Following 5-FU therapy a biopsy was obtained from the site of the treated BCC after ultrasound imaging had been performed. Clinical, ultrasonic and histopathologic evaluation of each BCC was carried out independently by different individuals. At the end of the study all the BCC sites were treated surgically be electrodesiccation and curettage or completely excised. RESULTS: High resolution ultrasound images of BCCs were obtained with agreement between histology and ultrasound findings in all none lesions prior to therapy and in eight of none lesions posttherapy. There was a significant correlation between the depth of BCCs measured histologically and using ultrasound (P = 0.0004, r = 0.92). CONCLUSIONS: This study suggests that 40-MHz ultrasound may provide an estimate of the boundary of a BCC in vivo. High frequency 40-MHz ultrasound imaging may be an adjunct to clinical and histologic evaluation but does not replace the need to obtain tissue for microscopic examination.

Perceived touch deprivation and body image: some observations among eating disordered and non-clinical subjects.

The developmental literature suggests that touch, consisting of secure holding and hugging, plays an important role in the formation of body image. We tested the hypothesis that women with anorexia nervosa and/or bulimia nervosa (N = 59), conditions associated with body image problems, report a greater deprivation of tactile nurturance than a sample of non-clinical randomly selected women (N = 140) from the community. Measures of body image included the Drive for Thinness and Body Dissatisfaction subscales of the Eating Disorder Inventory. Perceived touch deprivation was rated on a 10-point scale, previously developed by the author. Analysis of covariance, controlling for the effects of age and body mass index, revealed that the eating disorder group reported greater (p < 0.0001) body image concerns and perceived greater (p < 0.0001) touch deprivation both during their childhood and their current life, than the non-clinical group. Our preliminary empirical findings suggest that touch deprivation may play a role in body image pathologies.