BehindTheMedspeak: Psychodermatology — 'If You Think It, It Will Clear'

Natasha Singer's story in the July 28 New York Times about the rise of this new specialty caught my eye.

As did the great graphic (above) by the Dynamic Duo Studio that accompanied the article.

Long story short: psychodermatology can be nicely summarized by the quote in the headline of this post, also the Times headline.

Joe Duke, a Philadelphia purchasing agent, said in the article, "For me personally, biofeedback has been like anger management for my skin."

Tell you what: Joe Duke should be in advertising, not purchasing — he knows how to coin a slogan.

The Association of Psychocutaneous Medicine of North America had 12 founding members in 1991; it now numbers over 40 practitioners, including physicians and psychologists.

With a growth rate like that they'll reach triple figures by 2025.

Here's Singer's article.

If You Think It, It Will Clear

Stress may be inflaming your pimples.

And hypnosis may help clear them up.

Or deep breathing exercises.

Or maybe imagining yourself lying on a beach in Aruba.

At least that's the idea behind an emerging medical specialty that explores the interaction between the mind and the skin.

Its practitioners believe that for some patients, stress may play a role in skin conditions from acne to psoriasis, rosacea, warts, eczema, blushing and hives.

These doctors, who identify themselves as psychodermatologists - "derm shrinks" or "skin shrinks" for short - concentrate less on medicating the skin and more on getting at the psychological components of what ails it.

They do not ignore traditional medicine.

But they add treatments like psychotherapy, meditation, relaxation, hypnosis, acupuncture, yoga, tai chi and even anti-anxiety drugs.

These strategies, psychodermatologists say, have the potential to help the tens of millions of Americans who suffer from chronic skin ailments.

And many patients, frustrated by skin conditions that seem resistant to traditional medicine, are apparently willing to give them a try.

Mary O'Leary is one who has.

A surgical nurse in Boston, Ms. O'Leary had so many plantar warts on one foot, it was painful for her to stand all day in the operating room.

Her dermatologist prescribed antiviral creams, but nothing helped until she met Ted A. Grossbart, an assistant clinical professor of psychology at Harvard Medical School who specializes in skin problems.

"I spent months learning self-hypnosis," Ms. O'Leary said.

She visualized her immune cells fighting off the virus and imagined healthy skin replacing the warts.

"It's bizarre and amazing, but it worked."

Some doctors are skeptical of treatments based on stress relief.

Larry E. Millikan, chairman of the dermatology department at Tulane University School of Medicine in New Orleans, likened some psychodermatology methods to the wart-treating strategies Tom Sawyer recommended to Huckleberry Finn: burying a dead cat at midnight or sticking one's hand in a wet, rotten tree stump while chanting "spunk-water, spunk-water, swaller these warts!"

"The proven benefit for skin problems comes from traditional dermatology," Dr. Millikan said.

"That will remain true until we have hard science showing the effects of meditation and acupuncture on skin."

But psychodermatologists say the anecdotal evidence is enough to convince them that their approach is worthwhile.

"We all have patients whose hives, pimples and eczema get worse when their personal lives or work situations get complicated," said Dr. Richard G. Fried, a dermatologist and psychologist in Yardley, Pa., whose staff includes an acupuncturist and a biofeedback therapist.

"But dermatologists have customarily ignored the root causes and just treated the visible symptoms."

Joe Duke, a purchasing manager in Philadelphia, is one of Dr. Fried's patients.

"Two to three hours after a stressful situation," Mr. Duke said, "I used to get a psoriasis flare-up with 20 to 30 lesions across my chest, arms and legs. You look like a leper."

He had spent decades trying ultraviolet light treatments, prescription ointments and creams, antibiotics and even methotrexate, a drug that suppresses the immune system.

Some of these worked temporarily, while others had worrisome side effects. So Dr.

Fried suggested that Mr. Duke try biofeedback, which teaches patients to reduce tension by practicing deep breathing and muscle relaxation, and by imagining themselves in idyllic landscapes.

"I started biofeedback about 18 months ago, and last summer I even wore shorts for the first time in years," Mr. Duke said.

"For me personally, biofeedback has been like anger management for my skin."

The result, he said, has been fewer breakouts and less reliance on prescription creams.

The number of skin specialists who combine physical and psychological treatments appears to be rising.

The Association for Psychocutaneous Medicine of North America, which includes physicians and psychologists, has grown to more than 40 members from 12 in 1991.

Some of these practitioners treat depressed patients with disfiguring skin conditions or psychiatric patients who harm their own skin. But most also treat common skin ailments.

David Colbert, a dermatologist in New York, employs an acupuncturist to work with some of his rosacea and psoriasis patients.

And Philip D. Shenefelt, a dermatologist in Tampa, Fla., often uses hypnosis to treat itching or hives.

A few medical school dermatology programs also have begun to provide stress-relief treatments.

St. Luke's-Roosevelt Hospital in New York has a Psychocutaneous Medicine Unit where dermatologists and psychologists often treat patients in tandem.

And later this year the Johns Hopkins School of Medicine and the University of Rochester Medical Center plan to open psychodermatology clinics where doctors may recommend that patients try hypnosis or stress-reduction techniques.

Dr. Grossbart of Harvard, who has been treating skin complaints with psychotherapy for 25 years, said he was pleased that dermatologists were learning psychological techniques.

"If a dermatologist allots only 12 minutes to see each patient," he said, "that doesn't leave time to address underlying emotional issues."

Several recent studies have shown how stress can impair the skin.

In 2001 scientists at Weill Medical College of Cornell University subjected 25 volunteers to a fake job interview and 11 others to a sleepless night.

They then gave the volunteers microscopic wounds by peeling off a small, thin patch of skin with tape.

All the subjects' skin took longer than usual to repair itself.

A similar 2001 study, done at the University of California, San Francisco, looked at 27 graduate students during exam time and again during spring break.

While the students were studying for and presumably worrying about tests, their skin was slower to repair itself than it was during vacation.

There is less evidence to suggest that the opposite premise may be true: that reducing stress via hypnosis or meditation may heal the skin.

But there is some.

In 1998 a study of psoriasis patients at the University of Massachusetts found that those who listened to meditation tapes while receiving ultraviolet light treatments healed much faster than patients who did not use the tapes.

And a 1999 study at Johns Hopkins found that psoriasis patients who were susceptible to hypnosis treatments improved more than patients who resisted hypnosis.

The biological mechanisms by which these remedies may work are unknown.

It is possible that relaxation simply improves people's outlook and causes them to eat healthier food, sleep better and get more exercise, and that those changes affect their skin.

This uncertainty makes some doctors leery of mind-body treatments.

Mark Lebwohl, chairman of the dermatology department at Mount Sinai School of Medicine in New York, said that against his better judgment, he agreed to refer a psoriasis patient, Dennis Foglia of Queens, to a psychologist for hypnosis.

The therapist tried hypnosis and asked Mr. Foglia to visualize the rash leaving his body.

"I wouldn't tell other patients not to try it," said Mr. Foglia, a retired police officer, "but I can say hypnosis did not impact my psoriasis at all."

Richard D. Granstein, chairman of dermatology at Weill Medical College, questioned whether stress-relieving treatments could get rid of anyone's pimples.

"We can't be absolutely certain until we can prove that these therapies directly alter a patient's skin," Dr. Granstein said.

"It can't hurt your pimples to take up yoga or tai chi, as long as you're still using your acne creams."