Inflammatory skin diseases are often treated successfully with topical substances alone. The basic prerequisites for proper treatment are that the specialist has a good knowledge of the products available, their active substances and bases and their relative properties and actions, as well as precise indications for and effects of long-term use. Treatment should be individualized, and best results are usually achieved with a two-phase schedule, beginning mainly with administration of steroids followed by application of nonsteroid products, such as, in psoriasis, anthralin, coal tar, and calcipotriol.

Treumund Wellentreter) concluded that the mentally ill (he classified 36 different categories) were responsible for their actions and acquired a new soul (not heredity, perhaps not even predisposition was considered) when God punished them with the loss of personal will. It seems absurd that Heinroth should have been the one to create the neologism ‘psychosomatic’2. In fact, J. Taylor attributes the term to Coleridge, a poet, not a psychiatrist. When Plato wrote: ‘This is the great error of our times ... physicians see the body separate from the soul’, it was the baptism, if not the birth, of psychosomatics, and the statement was used by Weiss and English as the epigraph for their book Psychosomatic Medicine [2]. The authors, both at Temple University, Philadelphia, mentioned the founding of the Journal of Psychosomatic Medicine in 1939, which was applauded by the Journal of the American Medical Association in a very favorable article on Freud and his work (when Freud had already fled to London and many of his colleagues to the United States). Historically, scientific psychosomatics has been supported by psychoanalysts, beginning with Freud. Weiss and English commented that ‘no work could have been done in psychosomatic medicine without Freud’s work on biological psychiatry’. They point out that Freud’s discoveries were followed by the work of many others: Ferenczi, Abraham, Jones, Jelliffe, Deutsch, Wittkower, Menninger, Alexander, the group of the Chicago Psychoanalytic School, Flanders and Dunbar (‘Emotions and Somatic Variations’, published in 1935, reviews all the then existing literature on this subject), and the group of the Presbyterian Hospital in New York. The conclusion was that ‘all medicine must become (meaning: is) psychosomatic medicine’. Up to now, experiences and opinions originating from many very different cultures have accumulated. One of the fundamental problems is the hybrid status of psychosomatic epistemology. On the one hand, it is part of medicine with its empirical tradition; on the other hand, it refers to psychology with all related hermeneutic torments. The variEpistemology (or theory of knowledge, also called gnosiology) is defined in the Encyclopedia Britannica [1] as the study of the nature and validity of human knowledge. Epistemologists examine the degrees of certainty and probability in knowledge and the difference between knowing (with certainty) and believing (without being certain). This knowledge about knowledge can be used to provide a basis for wise action, security, and truth. Two competing epistemological orientations are Rationalism, which stresses the role of reason in providing certainty, and Empiricism, which stresses that of sensory perception. Here we propose an epistemology of psychosomatic dermatology for the 21st century, based on a review of the epistemology of psychosomatics, psychosomatic medicine, and, in particular, psychosomatic dermatology. The term ‘psychosomatic’ was coined in the second decade of the 19th century as a reflection on knowledge, certainties and truths, as well as opinions, hypotheses and interpretations with rationalistic and/or empirical bases: an examination which dermatology first restricted and then enlarged, from the res expansa, the skin, to the whole human body, and then to the body and mind together. The term ‘psychosomatic’ was coined in 1818 by J. Heinroth (1778–1843), a psychiatrist ‘ein Psychicher, nicht Somatiker’, in Leipzig, Germany1. In his History of Psychiatry, E.H. Ackernecht reminds us that metaphysics, mysticism, ‘morality’, and poetry provided the cultural bases for the Psychicher, distinguishing him from the Somatiker. The former considered all disease to be a result of sin. And thus Heinroth, psychiatrist and poet (under the pseudonym of

International Journal of DermatologyVolume 38, Issue 9 p. 673-675 Neuropeptides and skin disorders. The new frontiers of neuro–endocrine–cutaneous immunology Torello Lotti PhD, Torello Lotti PhD From the Department of Dermatology, University of Florence, Florence, ItalySearch for more papers by this authorBeatrice Bianchi PhD, Beatrice Bianchi PhD From the Department of Dermatology, University of Florence, Florence, ItalySearch for more papers by this authorEmiliano Panconesi MD, Emiliano Panconesi MD From the Department of Dermatology, University of Florence, Florence, ItalySearch for more papers by this author Torello Lotti PhD, Torello Lotti PhD From the Department of Dermatology, University of Florence, Florence, ItalySearch for more papers by this authorBeatrice Bianchi PhD, Beatrice Bianchi PhD From the Department of Dermatology, University of Florence, Florence, ItalySearch for more papers by this authorEmiliano Panconesi MD, Emiliano Panconesi MD From the Department of Dermatology, University of Florence, Florence, ItalySearch for more papers by this author First published: 05 April 2002 https://doi.org/10.1046/j.1365-4362.1999.00767.xCitations: 27 Torello Lotti, MD, Department of Dermatology, University of Florence, Via degli Alfani 37, 50121 Florence, Italy Read 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 onFacebookTwitterLinked InRedditWechat Citing Literature Volume38, Issue9September 1999Pages 673-675 RelatedInformation

There is controversy over whether the treatment of patients with ulcerative colitis (UC) with thiopurines increases their risk of lymphoma. We evaluated the risk of lymphoma (ongoing, residual, and per year of therapy) among thiopurine-treated patients with UC.We obtained nationwide data from the Veterans Affairs (VA) health care system from 2001 to 2011. We performed a retrospective cohort study, analyzing data on 36,891 patients from their date of diagnosis of UC in the VA health care system to a diagnosis of lymphoma or October 1, 2011 (subjects followed up for a median of 6.7 years). Thiopurine exposure was assessed using the VA pharmacy database. Patients who developed lymphoma were identified based on ICD-9 codes and confirmed by manual chart review.In total, 4734 patients with UC (13%) were treated with thiopurines for a median of 1 year. Lymphoma developed in 119 patients who had not been treated with thiopurines, 18 who were treated with thiopurines, and 5 who had discontinued treatment with thiopurines. The incidence rates of lymphoma were 0.60 per 1000 person-years among patients who had not been treated with thiopurines, 2.31 among patients who were treated with thiopurines, and 0.28 among patients who had discontinued treatment with thiopurines. The incidence rates of lymphoma during the first year, second year, third year, fourth year, and >4 years of thiopurine therapy were 0.9, 1.6, 1.6, 5, and 8.9 per 1000 person-years, respectively. The age-, sex-, and race-adjusted hazard ratios of developing lymphoma were 4.2 (95% confidence interval, 2.5–6.8; P < .0001) while being treated with thiopurines and 0.5 (95% confidence interval, 0.2–1.3; P = .17) after discontinuing treatment with thiopurines compared with patients who had not been treated with thiopurines.Based on a retrospective, nationwide cohort study, patients with UC have a 4-fold increase in risk of lymphoma while being treated with thiopurines compared with patients who have not been treated with thiopurines. The risk increases gradually for successive years of therapy. Discontinuing thiopurine therapy reduces the risk of lymphoma.

From a medical psychological point of view, acne vulgaris can be schematically divided into two clinical pictures: (1) the common adolescent eruption, more mind-influencing and thus somatopsychic; (2) the less frequent acne of adults (young adults for the most part), both as a continuation of adolescent acne and, more rarely, as a never before experienced cutaneous affection, and thus psychosomatic in a strict sense. We believe that the dermatologist can treat both of these clinical manifestations, even from a psychological aspect, from the very first visit with the patient using the first step in psychotherapy: counseling. The principal points of this approach are presented, with special attention to the differences to be considered in the two clinical pictures specified as well as to the opportuneness and timing of an eventual liaison consultation with psychologists/psychiatrists in realizing other therapeutic strategies.

Hypnosis utilizes trance to access otherwise inaccessible repressed or unconscious memories and features of the psyche and control of physiology not attainable in the ordinary conscious waking state. Medical uses of hypnosis in dermatology include reducing discomfort from itching or skin pain, altering ingrained dysfunctional habits such as scratching, promoting healing of skin disorders, searching for psychosomatic aspects of skin disorders and alleviating them, and reframing cognitive and emotional dysfunctional patterns related to skin disorders. Meditation uses trance to center and balance. Medical uses of meditation in dermatology include relaxation to promote healing of skin disorders and refocusing with respect to the meaning and emotional negative valance of skin disorders. Biofeedback in dermatology employs instrumentation with visual or auditory feedback to permit conscious awareness and alteration of physiologic phenomena such as sweating as measured by galvanic skin resistance and skin temperature measured by temperature detecting devices, promoting relaxation and healing. These methods and techniques permit access to and intervention in otherwise inaccessible areas that can influence skin disorders. With proper use, they are very safe, with minimal, if any, side effects and sometimes produce significant results where other methods have failed.

Proopiomelanocortin (POMC) is a 29 kD protein that is processed post-translationally in the anterior pituitary to yield the peptides ACTH, betaendorphins and beta-lipoprotein. Extra-pituitary sites of synthesis include the brain, gonads, gastrointestinal tract, placenta and lymphocytes. Here we show the mRNA encoding proopiomelanocortin (POMC) by Northern blot hybridization analysis of RNA extracted from the epidermoid cell line A431. Treatment of keratinocytes with lypopolysaccharide (LPS), phorbolmiristate acid (PMA) (50 mu g/ml), Corticotropin Releasing factor (CRF) plus Arginin Vasopressin Peptide (AVP) (0,1 mu g/ml) for 12 and 24 hours and UVB (30 mJ/cmq) irradiation influences the POMC gene expression. After 12 hours incubation PMA and UVB irradiation are evident to upregulate POMC mRNA transcription while LPS and CRF+AVP showed little or no influence on POMC gene expression. After 24 hours stimulation also LPS and CRF+AVP resulted to moderately increase the POMC mRNA transcription.

Itraconazole and fluconazole are azole derivatives widely used in the treatment of dermatophyte infections. The aim of the pre sent clinical investigation was to compare the efficacy and safety of these antifungal drugs in the treatment of tinea corporis. In this multicenter, double-blind, comparative study, 38 patients with mycologically confirmed tinea corporis were randomized to receive treatment with itraconazole (100 mg/day) or fluconazole (50 mg/day) for 15 days. Thirty-seven of the patients were evaluable at the end of the trial. Both drugs resulted in a marked improvement in, or elimination of, all clinical symptoms; however, the mean score for inflammation and desquamation was consistently lower in the itraconazole group. The number of patients with positive mycological findings was also reduced, so that at the end of the 2-week treatment, 72.2 % of patients receiving itraconazole and 47.4 % of those treated with fluconazole had negative results. However, the overall assessment at the end of the 10-week follow-up did not show significant differences between the groups, with 94.4 % (itraconazole) to 84.2 % (fluconazole) of patients being clinically and mycologically cured. Mild adverse events were reported by 3 patients treated with fluconazole and one subject receiving itraconazole. Although itraconazole appears to be associated with a faster clinical response and higher frequency of mycological clearance, the results suggest that itraconazole is as effective as fluconazole in the treatment of tinea corporis.

Stress is an abnormal or extreme adjustment in the physiology of an animal to cope with adverse effects of its environment and management. The adverse effect is designated the stressor. In this article, the authors try to focus on the main types of host factors that can influence stress (genetics, perception) and on the numerous types of stressors (environmental, behavioral, psychological). Moreover, the authors outline the relevance of psychosomatic medicine, proposing the examination of psyche and soma as a unit "in sickness and in health." They focus their attention on the new aspects of biologic psychosomatics (psychoneuroendocrinimmunology) in dermatology, suggesting the possible role of neuropeptides in the pathogenesis of some common dermatoses such as psoriasis, atopic dermatitis, alopecia areata, and urticaria.

Background It has been reported that azole derivatives are useful in the treatment of dermatophytoses, also in tinea pedis and tinea manuum.

Stress is a term that is readily recognized by everyone but defines rigorous scientific definition. It is widely interpreted as the emotional and biologic responses to novel or threatening situations. In humans, however, the term ''distress'' seems to be preferable, more clearly defining the fact that is the response that is being referred to, rather than the stimulus. Distress has been postulated to be capable of precipitating an overt illness, as when it occurs coincidentally with an incipient infection or neoplasm. Moreover, it is able to provoke several disorders and symptoms in many tissues and organs, including the skin. In this paper the authors focus on the main characteristics of stress and emphasize the relevance of psychosomatic medicine that proposes the simultaneous examination of psyche and soma. Special consideration is given to a peculiar form of skin disease, psychogenic purpura, together with the stigmata of mystics that, in large part, seem to be conditioned or provoked (or provocable) by emotional stress or by psychic influences on cutaneous fibrinolytic activity.

Idisordered maturation of myeloid cells.A theoreticpossibility exists that GM-CSF stimulated someofthoseabnormal clones and caused exacerbationof psoriasis.GM-CSF was used along with cytosine arabinoside in their patient.Current observations suggest that a critical balance of various cytokinesis a key factor in the pathogenesis of psoriasis.H The effect of GM-CSF alone and GM-CSF combinedwith cytosinearabinosideon the cytokine network could be totally different.Little is knownabout the role of GM-CSF inpsoriasis.These contradictoryobservations require further studies.I agree that it is not wise to generalize on the basis of a few case reports; we also mentioned that in our report.The explanation given by Kelly and Marsden regarding exacerbation of psoriasis by GM-CSF does not hold in our patient.Our patient is still receiving maintenance doses of GM-CSF for aplastic anemia, and his psoriasis remains in remission.

A 57‐year‐old woman presented with symmetrical reddish‐brown plaques on the entire skin, especially the extremities. The lesions differed in size and shape, and their consistency ranged from soft to tight‐elastic, to hard in the older lesions (Fig. 1). The forearms and the dorsae of the hands and feet were covered with confluent plaques; some of these had an isolated nodular lesion on top. The lesions on the arms were papular‐nodular, arranged in rows to form “cords” with “pseudokeloid” appearance (Fig. 2). On the face, around the cheeks, the wings of the nose, and the ears, there were purplish nodular lesions and plaques. The lesions first appeared 14 years ago in the winter as lentile‐sized, slightly reddish papules on both legs. These lesions disappeared spontaneously during the summer and returned the following winter. For 4 years the lesions followed this pattern of appearing and disappearing, leaving residual pigmentation. The patient reported that at each recurrence the lesions were larger and darker. Subsequently, the lesions had become permanent without any improvement during the summer and had also spread to the upper limbs and trunk. For the past 4 years the patient has had arthralgia of the large joints, swelling of the lower extremities, burning and pain in the lesions themselves. These symptoms became more evident in the evening and after exposure to cold. A biopsy specimen of a recent lesion showed a dermal perivascular infiltrate comprised mainly of neutrophilic granulocytes and histiocytes and a few eosinophils. The vessels appeared dilated with swelling of the endothelial cells (Fig. 3). In and around the vessel walls an eosinophilic deposit of fibrinoid material was noted. Electronmicroscopic examination revealed macrophages with secondary lysosomes containing electrondense, osmiophilic, probably lipid material, in the perivascular infiltrate. lnterdigitate cells, juxtaposed with the lymphocytes among the infiltrate cells were also seen (Fig. 4). Direct immunofluorescence (DIF) revealed linear IgA deposits at the dermoepidermal junction. Direct immunofluorescence on healthy perilesional skin after histamine injection 1 showed IgA, C3, and fibrinogen at the perivascular level in the superficial dermis and at the dermoepidermal junction with granular appearance. Cutaneous fibrinolytic activity (CFA) evaluated with Todd's autohistographic method 1 , modified by Lotti et al. 2 , was reduced by 80% compared to that of healthy subjects. Findings of other laboratory tests are listed in Table 1. Relevant investigations showed a decrease in fibrinogen, positive protein C and RA tests, the presence of cryoglobulin, and an increase in serum |gA.| Circulating immune complexes were detected and glucose‐6‐phosphate‐dehydrogenase (GG‐PD) was slightly low. The tests of clotting function showed some changes due to increased platelet aggregability from exogenous adenosine diphosphate (ADP), a slight reduc‐tion in fibrinogenemia due to the presence of D‐dimers and other products of fibrinogen degradation, suggesting a state of chronic intravascular coagulation. Treatment was begun with diaminodiphenylsulfone (50 mg/day), which was suspended because of adverse reac‐tions (headache and nausea) and was replaced by clofa‐zimine (starting dose 200 mg/day). Improvement in the sub‐jective symptoms and healing of many lesions with residual pigmentation was noted.

Seventy-six patients with severe diffuse plaque-form psoriasis and a baseline PASI score greater-than-or-equal-to 18 were enrolled in a randomized open study comparing cyclosporin 5 mg/kg/day (36 patients) with etretinate 0.75 reduced to 0.5 mg/kg/day (40 patients) over a period of 3 months (phase 1). The rate, severity and time to relapse after the withdrawal of therapy in the 54 patients achieving remission were evaluated over the following 6 months (phase 2). Twelve of these patients entered an open, uncontrolled phase aimed at defining the safety and the strategy of cyclosporin 2.5-5 mg/kg/day maintenance therapy over a further period of 9 months (phase 3). Patient tolerability, laboratory parameters and blood pressure were carefully monitored every week for the first 3 months and then monthly. The only concomitant therapy allowed was white petrolatum. Not only the number (35/36 vs. 29/40) but also the speed of remission (20/36 vs. 1/40 at the fourth week of treatment) was higher in the cyclosporin than in the etretinate group. Both the tolerability and safety of cyclosporin proved to be adequate for short-term treatment, all altered clinical or laboratory parameters being completely reversible after the withdrawal of therapy. Only 1 of the 36 patients in the cyclosporin group prematurely stopped taking the medication because of an adverse reaction, as against 7/40 in the etretinate group (1 case of inefficacy, 1 case of adverse reaction and 5 cases of non-compliance). Six months after the discontinuation of the trial drugs, relapses occurred in 13/29 patients in the cyclosporin group and in 3/25 in the etretinate group; no 'rebound' was observed in any of the relapsing patients. Long-term cyclosporin treatment was both efficacious and well tolerated. In conclusion, cyclosporin at doses of 2.5-5 mg/kg/day administered to reliable, carefully selected patients closely monitored in terms of both clinical and laboratory parameters currently produces the quickest and more constantly favourable results in patients with severe psoriasis.