Atopic dermatitis (AD) is a chronic inflammatory skin disease with a significant psychological impact. The cardinal symptom of all phenotypes and severities is chronic pruritus with repetitive itching and scratching due to a vicious itch-scratch cycle that can be worsened or triggered by stress. Neuroimaging of brain areas responsible for itch processing in healthy subjects versus patients with AD has provided insights into the brain circuits involved in itch central perception. In patients with AD, the dorsolateral prefrontal cortex appears to be overactive while regulating the itch-scratch circuit, and this persistent hyperactivation over time may disrupt this brain region. Common mechanisms between addiction and scratching could explain why some patients with AD continue to scratch despite showing clinical improvements from conventional treatments. In addition, molecular knowledge indicates bidirectional neuroimmune circuits between the peripheral nervous and immune system and dysregulated skin cells may aggravate and perpetuate AD severity. We provide an overview of the basic mechanisms that underlie the itch-scratch cycle in AD, especially neural sensitization of nonhistaminergic itch-specific pathways, and discuss how integrative therapies may interfere with central and peripheral mechanisms of chronic itch to reduce neuroinflammation and break the itch-scratch cycle. The connection between mind and body in the itch-scratch cycle, involving central mechanisms, suggests that integrative and multidisciplinary treatment approaches could be helpful as an adjunct to pharmacological treatment in the clinical management of AD. Integrative therapies may potentially help to reduce pruritus and scratching, psychological stress and sleep disturbances, and improve immune and skin barrier dysregulation, AD outcomes, and patient well-being.

Background:Skin diseases are symptomatic, visible, and stigmatizing and it is acknowledged that they can be associated with stress. However, large studies comparing disease-specific stress are scarce. Objectives:To investigate stress in a large, diverse sample of patients with different skin conditions and identify predictors of stress. Methods:A cross-sectional, multicenter study was conducted in 22 dermatology clinics across 17 European countries (response rate 82.4%). The study included 5487 patients diagnosed with various dermatological conditions and 2808 skin-healthy controls. The Perceived Stress Scale, 10 items was used to measure stress. Results:Patients reported significantly higher stress levels, more stressful life events during the last 6 months, and more economic difficulties than controls. Patients with psychodermatological conditions, hyperhidrosis, hidradenitis suppurativa, atopic dermatitis, acne, and urticaria experienced the highest stress levels. 44% of the variance of perceived stress in patients with skin conditions could be predicted by sociodemographic data and disease-related and psychological variables (depression, anxiety, stigmatization, and body dysmorphic concerns). Limitations:As with all cross-sectional studies, causality and directionality cannot be inferred. Conclusion:Stress poses a significant psychosocial burden to dermatological patients, especially to vulnerable subgroups. Health interventions targeting stress may be essential to improve clinical outcomes.

Chronic pruritus (CP) is defined as an unpleasant sensation causing a desire to scratch and lasting > 6 weeks. It has a multifactorial etiology but is more frequently associated with chronic inflammatory dermatoses and systemic disorders. Psychogenic pruritus and neurological disorders are other less common etiologies, while, in some patients, it is idiopathic. CP appears to be processed by non-histaminergic pathway, contributing to its complexity and therapeutic challenge. Moreover, regardless of the etiology, it is multidimensional, including cognitive, motivational and affective components. There is a close link between psychological distress and pruritus, with particular clinical expression in chronic inflammatory dermatoses, involving the activation of the hypothalamic-pituitary-adrenal axis (and its cutaneous equivalent), the sympathetic nervous system, the release of hormones and peptides, the role of immune cells (T and B cells, macrophages) and immune-related cells in the skin (mast cells, dendritic cells and keratinocytes). Moreover, there is strong evidence that psychological factors influence the experience of pruritus. CP can also cause psychiatric disorders, including but not limited to anxiety and depression, and also lead to significant quality of life (QoL) impairment. Thereby, although a psychodermatological assessment should ideally be carried out in the context of a specific psychodermatology consultation, a brief mental health assessment could be part of the general dermatological approach to these patients. Considering that mental health, QoL and pruritus are closely linked, psychotherapeutic interventions and/or psychotropic drugs should thus be considered in some patients as an adjunct to the pharmacological treatment of CP.

Journal of the European Academy of Dermatology and VenereologyEarly View LETTER TO THE EDITOR Alexithymia and dissociation in psychogenic pruritus: Clinical relevance and therapeutic implications Bárbara Roque Ferreira, Corresponding Author Bárbara Roque Ferreira [email protected] orcid.org/0000-0002-4808-6398 University of Brest, LIEN, Brest, France Department of Dermatology, Centre Hospitalier de Mouscron, Mouscron, Belgium Correspondence Bárbara Roque Ferreira, University of Brest, LIEN, Brest, France. Email: [email protected]Search for more papers by this authorLaurent Misery, Laurent Misery orcid.org/0000-0001-8088-7059 University of Brest, LIEN, Brest, France Department of Dermatology, Brest University Hospital, Brest, FranceSearch for more papers by this author Bárbara Roque Ferreira, Corresponding Author Bárbara Roque Ferreira [email protected] orcid.org/0000-0002-4808-6398 University of Brest, LIEN, Brest, France Department of Dermatology, Centre Hospitalier de Mouscron, Mouscron, Belgium Correspondence Bárbara Roque Ferreira, University of Brest, LIEN, Brest, France. Email: [email protected]Search for more papers by this authorLaurent Misery, Laurent Misery orcid.org/0000-0001-8088-7059 University of Brest, LIEN, Brest, France Department of Dermatology, Brest University Hospital, Brest, FranceSearch for more papers by this author First published: 04 March 2024 https://doi.org/10.1111/jdv.19918Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat No abstract is available for this article. REFERENCES 1Misery L, Dutray S, Chastaing M, Schollhammer M, Consoli SG, Consoli SM. Psychogenic itch. Transl Psychiatry. 2018; 8(1): 52. 10.1038/s41398-018-0097-7 Google Scholar 2Ferreira BR, Misery L. Psychopathology associated with chronic pruritus: a systematic review. Acta Derm Venereol. 2023; 103:adv8488. 10.2340/actadv.v103.8488 Web of Science®Google Scholar 3 American Psychiatric Association. DSM-5: diagnostic and statistical manual of mental disorders. 5th ed. Washington, DC: Author; 2013. 10.1176/appi.books.9780890425596 Google Scholar 4Sawant NS, Umate MS. Dissociation, stressors, and coping in patients of psychogenic nonepileptic seizures. Indian J Psychol Med. 2021; 43(6): 479–484. 10.1177/0253717620956460 Google Scholar 5Reyno SM, Simmons M, Kinley J. A meta-analytic study examining the relationship between alexithymia and dissociation in psychiatric and nonclinical populations. Res Psychother. 2020; 23(1): 439. Web of Science®Google Scholar 6Alexithymia BM. In: M Bouvard, editor. In: Questionnaires et échelles d'évaluation de la personnalité. Paris: Elsevier Masson; 2009. p. 233–246. Google Scholar 7Larøi F, Billieux J, Defeldre AC, Ceschi G, Van der Linden M. Factorial structure and psychometric properties of the French adaptation of the dissociative experiences scale (DES) in non-clinical participants. Eur Rev Appl Psychol. 2013; 63: 203–208. 10.1016/j.erap.2013.04.004 Web of Science®Google Scholar 8Carlson E, Putman FW. An update on the dissociative experience scale. Dissociation. 1993; 6(1): 16–27. Google Scholar 9Lyssenko L, Schmahl C, Bockhacker L, Vonderlin R, Bohus M, Kleindienst N. Dissociation in psychiatric disorders: a meta-analysis of studies using the dissociative experiences scale. Am J Psychiatry. 2018; 175(1): 37–46. 10.1176/appi.ajp.2017.17010025 PubMedWeb of Science®Google Scholar 10Majohr KL, Leenen K, Grabe HJ, Jenewein J, Nuñez DG, Rufer M. Alexithymia and its relationship to dissociation in patients with panic disorder. J Nerv Ment Dis. 2011; 199(10): 773–777. 10.1097/NMD.0b013e31822fcbfb PubMedWeb of Science®Google Scholar Early ViewOnline Version of Record before inclusion in an issue ReferencesRelatedInformation

BackgroundItch as the most common symptom in dermatology has been shown to be related to psychological factors such as stress, anxiety and depression. Moreover, associations were found between perceived stigmatization and itch. However, studies investigating the differences between patients with dermatoses with and without itch regarding perceived stress, stigmatization, anxiety and depression are missing. Therefore, one of the aims of the second study of the European Society for Dermatology and Psychiatry (ESDaP study II) was to investigate these relationships in a large cohort of patients with different itchy dermatoses.Results3399 patients with 14 different itchy dermatoses were recruited at 22 centres in 17 European countries. They filled in questionnaires to assess perceived stigmatization, stress, signs of clinically relevant anxiety or depression, itch-related quality of life, the overall health status, itch duration, frequency and intensity. The most significant association between the severity of itching and the perception of stress was observed among individuals with rosacea (correlation coefficient r = 0.314). Similarly, the strongest links between itch intensity and experiences of stigmatization, anxiety, and depression were found in patients with seborrheic dermatitis (correlation coefficients r = 0.317, r = 0.356, and r = 0.400, respectively). Utilizing a stepwise linear regression analysis, it was determined that within the entire patient cohort, 9.3% of the variation in itch intensity could be accounted for by factors including gender, levels of anxiety, depression, and perceived stigmatization. Females and individuals with elevated anxiety, depression, and perceived stigmatization scores reported more pronounced itch intensities compared to those with contrary attributes.ConclusionThis study underscores the connection between experiencing itch and its intensity and the psychological strain it places on individuals. Consequently, psychological interventions should encompass both addressing the itch itself and the interconnected psychological factors. In specific cases, it becomes imperative for dermatologists to direct individuals towards suitable healthcare resources to undergo further psychological assessment.

Gender dysphoria is defined as a condition characterized by mental suffering associated with the incongruence between one’s experienced gender and their birth-assigned sex. Gender as a construct and gender dysphoria as a condition in need of multidisciplinary intervention have developed as swiftly as their visibility in society, making it mandatory to promote the literacy and education of all healthcare professionals in this area. This article aims to review information based on scientific evidence on people with gender dysphoria and its clinical approach, while contributing to a safe, inclusive, and non-discriminatory practice of healthcare.

Atopic dermatitis (AD) is a chronic inflammatory skin disease with a complex pathophysiology characterized by intense pruritus, often associated with psychological stress and atopic and non-atopic comorbidities that significantly reduce quality of life. The psychological aspects of AD and the interaction between the mind and body via the skin–brain axis have led to an interest in mind–body therapies (MBT). The aim of this article is, therefore, to reinforce the importance of psychodermatological care in AD. We performed a focused literature review on holistic practices or integrative MBT in AD, including education, cognitive behavioral therapy, habit reversal, meditation, mindfulness, hypnotherapy, eye movement desensitization and reprocessing, biofeedback, progressive muscle relaxation, autonomous sensory meridian response, music therapy, massage, and touch therapy. A multidisciplinary holistic approach with MBT, in addition to conventional pharmacologic antipruritic therapies, to break the itch–scratch cycle may improve AD outcomes and psychological well-being. Although there is a paucity of rigorously designed trials, evidence shows the potential benefits of an integrative approach on pruritus, pain, psychological stress, anxiety, depressive symptoms, and sleep quality. Relaxation and various behavioral interventions, such as habit reversal therapy for replacing harmful scratching with massaging with emollient ‘plus’, may reduce the urge to scratch, while education may improve adherence to conventional therapies.

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This case report explores the interplay between childhood trauma, social phobia, psychotic symptoms, and minority stress in a 27-year-old transgender male. L presented with psychotic symptoms, including auditory verbal hallucinations and self-referential phenomena, which were accompanied by a history of childhood sexual and emotional abuse, as well as social phobia. These challenges were further compounded by experiences of stigma, rejection, and stress related to his gender identity. We explore how affective dysregulation and maladaptive cognitive patterns, potentially shaped by past trauma, might influence psychotic symptoms, particularly in the form of auditory verbal hallucinations that are sensitive to social contexts. Addressing underlying trauma-related beliefs and anxiety can help mitigate psychotic symptoms, improve social functioning, and enhance treatment outcomes, offering an integrated pathway for recovery.

INTRODUCTION:Hidradenitis suppurativa (HS) can severely affect the quality of life (QoL) and is linked to psychological distress, including anxiety, depression, and reduced self-esteem. Stigmatization due to physical appearance may significantly contribute to the psychological burden and impact on QoL for HS patients. This study investigates the association between stigmatization, depression, anxiety, and health- and disease-related variables among HS patients in Europe. PATIENTS AND METHODS:This observational cross-sectional multicenter study was conducted across 22 dermatological outpatient clinics in 17 European countries. Data collected included sociodemographic variables, general health variables, disease-related variables, perceived stigmatization (PSQ), and mental health (PHQ-2, GAD-2). RESULTS:Of the 5487 dermatological patients, 142 (2.6%) were diagnosed with HS, and data from 135 patients (70.1% women, mean age 38.2 years) who completed the PSQ questionnaire were analyzed. Scores on the stigmatization measure indicated that significant stigmatization levels were present in the sample. Linear regression models revealed a significant relationship between stigmatization and both the duration of HS and the presence of itch. Similar findings were noted for the PSQ "confused/staring behavior" scale with depression. The PSQ "absence of friendly behavior" scale was inversely associated with general health status, whereas the "hostile behavior" scale was positively linked to depression. CONCLUSION:HS patients experience significant stigmatization linked to disease duration, itch, and depression. Comprehensive management, including screening for psychosocial co-morbidity, is essential, as is providing access to psychological interventions that support patients to both manage internal distress and the potential reactions of others.

BackgroundDysmorphic concern is an overconcern with an imagined or slight defect in physical appearance that can be a symptom of body dysmorphic disorder (BDD). Appearance-related concerns are frequently reported by people with dermatological conditions. However, relatively little remains known about the relationship between dysmorphic concern and other variables within persons with different skin conditions.ObjectivesThe aim of this multicentre, cross-sectional study was to investigate gender differences regarding dysmorphic concern and the prevalence of BDD in a large sample of patients with skin conditions, in relation to sociodemographic, clinical and psychological variables.MethodsParticipants aged >= 18 years with skin conditions were consecutively enrolled in dermatological clinics of 22 European centres. Dysmorphic concern and the possible presence of BDD were measured using the Dysmorphic Concern Questionnaire (DCQ) and compared between men and women in relation to sociodemographic, clinical and psychological variables, and separately for each skin condition.ResultsThe DCQ questionnaire was completed by 5290 dermatological patients. In all categories, mean scores were significantly higher in women than in men. Mean DCQ scores were also higher in women for most skin conditions, with the highest effect size in vitiligo. The percentage of patients who screened positive for BDD on the DCQ was 10.5%, 7.7% of men and 12.7% of women. The prevalence of BDD positive was 6.9% in patients with mild clinical severity, 11.1% for moderate and 19.1% for severe condition. In the multivariate model in patients with mild skin condition, the presence of BDD was positively associated with stress and stigma both in men and in women.ConclusionsDysmorphic concern and BDD were more frequent in women than in men with skin conditions. Both received and actual stigmatization might have an impact on body-related concerns, in particular in women, who may be more at risk for sociocultural reasons. image

Data sharing is not applicable to this article as no new data were created or analysed in this study.

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.

There are no previous studies of the psychopathology associated with different aetiologies of chronic pruritus. A systematic review was performed of cohort and case-control studies comparing healthy controls with patients with chronic pruritus related to primary dermatoses, systemic diseases, psychogenic pruritus, idiopathic pruritus, prurigo nodularis and/or lichen simplex chronicus. The review was registered in PROSPERO and performed according to the PRISMA statement, which allowed the inclusion of 26 studies. The quality of eligible studies was assessed using the modified Newcastle-Ottawa Scale. Most of the studies concern primary dermatoses and systemic diseases. Sleep disorders are a common comorbidity interrelated with pruritus, anxiety and depressive symptoms, in primary dermatoses. Sleep disorders are linked with pruritus and depressive symptoms in end-stage renal disease and hepatobiliary disease. Depressive and anxiety symptoms are associated with psychogenic pruritus. Psychogenic pruritus, lichen simplex chronicus and some primary dermatoses are linked with personality characteristics. Further studies are required to explore in depth the psychopathology linked with psychogenic pruritus and prurigo nodularis, as well as psychopathology linked with other primary dermatoses and systemic disorders associated with chronic pruritus, and to better differentiate psychogenic pruritus from psychopathological characteristics linked with other aetiologies of chronic pruritus, in order to improve the management of patients with chronic pruritus.

Psychodermatology is a subdiscipline of dermatology at the intersection of dermatology, psychiatry, and psychology. In dermatology clinical practice, patients may present with skin disease that affects their mental health, or skin disorders induced or worsened by psychological/psychiatric problems so there is a need for specialised education of dermatologists, as well as multidisciplinary teams, to achieve better management of these patients. Understanding the interaction between the central nervous system and the skin underlying psychocutaneous disorders could help identify alternative therapies that may improve patient well‐being. The concept of pleasurable touch has received increasing attention following the discovery of C‐tactile (CT) fibres. While afferent C‐fibre stimulation is usually associated with pain, temperature, or itch, CT‐fibres are stimulated optimally by a stimulus not in the nociceptor range but by a gentle, low‐force stroking. As this affective touch may counteract unpleasurable sensations, such as pain and itch, and elicit positive feelings, the potential benefits of gentle touch and massage are interesting for dermatological, especially psychocutaneous, disorders. Here we provide an overview of the skin‐brain connection to help understand the benefits of touch and massage, as illustrated with studies on atopic dermatitis and burns, as an adjunct to dermatological treatment for improving patient well‐being and optimising treatment outcomes.

INTRODUCTION:Several classifications of psychodermatology disorders have been proposed, with most of them based on two to four main disorder category groups. However, there is, to date, no classification that has resulted from a consensus established by psychodermatology experts. The DSM-5-TR (Diagnostic and statistical manual of mental disorders (5th ed.), Text Revision) and the ICD-11 (International classification of diseases (11th revision)) also do not provide a systematized approach of psychodermatology disorders. Taking into consideration that classifications are a key pillar for a comprehensive approach to the pathologies of each branch of medicine, the proposal of a classification in psychodermatology appeared as a central need for the recognition of psychodermatological disorders, in an attempt to improve their recognition and, in that sense, to find a common language for the development of this subspecialty that crosses dermatology and psychiatry. METHODS:Previously published classifications in psychodermatology were critically reviewed and discussed by expert opinion from an international multidisciplinary panel of 16 experts in psychodermatology and a new classification system is proposed, considering classical concepts in general dermatology and psychopathology. RESULTS:Two main categories of disorders are presented (a main group related to primary mental health disorders and another main group related to primary skin disorders), which are subsequently subdivided into subgroups considering pathophysiological and phenomenological similarities, including key aspects of dermatological examination, namely the presence of visible skin lesions (primary and secondary skin lesions) and psychopathological correlates. CONCLUSION:This new classification aims to unify previous classifications, systematize the disorders that belong to psychodermatology and highlight their tenuous boundaries, to improve their management. It has been built and approved by the Psychodermatology Task Force of the European Academy of Dermatology and Venereology (EADV), the European Society for Dermatology and Psychiatry (ESDaP) and the Association for Psychoneurocutaneous Medicine of North America (APMNA).

Background Body dysmorphic disorder (BDD) is a common psychiatric disorder associated with high costs for healthcare systems as patients may repeatedly ask for different, often not effective, interventions. BDD symptoms are more prevalent in patients with dermatological conditions than in the general population, but there are no large sample studies comparing the prevalence of BDD symptoms between patients with dermatological conditions and healthy skin controls. Objectives To compare the prevalence of BDD symptoms between patients with different dermatological conditions and healthy skin controls and to describe sociodemographic, physical and psychological factors associated with BDD symptoms to identify patients who may have a particularly high chance of having this condition. Methods This observational, cross-sectional, comparative multicentre study included 8295 participants: 5487 consecutive patients with different skin diseases (56% female) recruited among dermatological outpatients at 22 clinics in 17 European countries, and 2808 healthy skin controls (66% female). BDD symptoms were assessed by the Dysmorphic Concern Questionnaire. Sociodemographic data and information on psychological factors and physical conditions were collected. Each patient was given a dermatological diagnosis according to ICD-10 by a dermatologist. The study was registered with number DRKS00012745. Results The average participation rate of invited dermatological patients was 82.4% across all centres. BDD symptoms were five times more prevalent in patients with dermatological conditions than in healthy skin controls (10.5% vs. 2.1%). Patients with hyperhidrosis, alopecia and vitiligo had a more than 11-fold increased chance (adjusted Odds Ratio (OR) > 11) of having BDD symptoms compared with healthy skin controls, and patients with atopic dermatitis, psoriasis, acne, hidradenitis suppurativa, prurigo and bullous diseases had a more than sixfold increased chance (adjusted OR > 6) of having BDD symptoms. Using a logistic regression model, BDD symptoms were significantly related to lower age, female sex, higher psychological stress and feelings of stigmatization. Conclusions Clinical BDD symptoms are significantly associated with common dermatological diseases. As such symptoms are associated with higher levels of psychological distress and multiple unhelpful consultations, general practitioners and dermatologists should consider BDD and refer patients when identified to an appropriate service for BDD screening and management. What is already known about this topic? Body dysmorphic disorder (BDD) is a common psychiatric disorder with a prevalence of about 2% in the general population. Skin diseases pose a high psychological burden on patients. People with these problems often experience increased self-consciousness, skin-related shame and stigmatization. Single-centre studies including small samples of patients with skin conditions showed that these patients show symptoms of a similar nature to BDD more often than the general population. What does this study add? In this large multicentre study, BDD symptoms were fivefold more prevalent in dermatological patients than in healthy skin controls, and were related to young age, female sex, psychological stress and stigmatization experience. Certain patient groups (e.g. hyperhidrosis) had a greater than 11-fold increased chance of BDD symptoms compared with controls. Doctors should consider appearance-related concern and BDD more often and refer patients when needed to an appropriate service for assessment and treatment.

The impact of the coronavirus disease 2019 (COVID-19) pandemic on mental health has been reflected in different populations worldwide. It has caused significant psychopathological consequences in general population, healthcare professionals (e.g., dermatologists), patients with COVID-19, and patients with other diagnoses, including skin diseases. The prevalence of psychiatric comorbidities in dermatology has long been reported to be at least 30 percent. It is important to investigate the pandemic's impact on comorbid psychosocial and psychopathological symptoms seen in dermatology, including expected short- and long-term mental health consequences. The authors seek to raise awareness among healthcare professionals of the impact that COVID-19 is having on existing psychodermatological conditions and discuss the practical implications of this relationship in dermatology.