Françoise Poot - ULB-Erasme Hospital – Brussels – Belgium

As psychodermatology is a new topic in the field of dermatology, the necessary conditions to practice this approach are not clear and not defined. The European building of a certificate for psychotherapy will force us to better elaborate what we want to do for our patients and what are the minimal requirements needed. This will also be a guarantee for our patients.

The purposes of this lecture will be to better define and give in some words the basic knowledge we need for this subspecialty. It will try to answer to the question of what is necessary to become a “psychodermatologist” if we are working alone or to start a psychodermatology oriented consultation if we are working in a team with a psychologist or psychiatrist and even if we are working alone as a psychiatrist specially interested in psychodermatology.

1. Is the psychodermatology consultation a psychotherapy? In  what case? How can we give a  

    frame to it?

2. What is the special profile of our patients? Are they different  than other psychosomatic

    patients? What is a psychosomatic  patient?

3. What education and personal investment do we need? Who  is able to become a

    psychodermatologist?

4. How can we evaluate the problem of the patient and plan with him a way for going out of his

    difficulties?

There is no royal road in helping our patients. We need openness and integration of parts from different approaches. A sane eclecticism is necessary together with a good basic theoretical

knowledge. We need also a personal investment to give empathy to our patients and to work on our own difficulties.

Rainer Haberberger and *Volker Niemeier Institutes for Anatomy and Cell Biology and Psychosomatic Medicine*, Justus-Liebig-University Giessen Neurogenic inflammation of the skin is induced by the activation of nociceptive nerve fibres followed by vasodilation and an increase in vascular permeability. Nociceptors belong to the group of unmyelinated (C-fibre) or myelinated (A-fibre) sensory nerve fibres that innervate different structures in the skin. These fibres originate from dorsal root ganglia (DRG) situated in the intervertebral foramina. Neurochemically distinct populations of sensory DRG neurons project to different regions of the skin. Specific receptors in the endings of those afferent nerve fibres in the skin can be activated by a huge variety of substances including transmitters, proteases, protons and cytokines. Activation of the nerve endings in the skin is followed by the generation of action potentials that are conveyed centrally to the laminae I and II of the spinal cord dorsal horn. Stimulation of the nerves also leads to the release of “proinflammatory” substances from peripheral nerve endings. The Calcitonin-gene-related peptide (CGRP) and substance P (SP) are two neuropeptides that are present in C- and A-fibre afferents and that are released upon stimulation of peripheral nerve endings. CGRP and SP induce pruritus, dilate arterioles, increase vascular permeability and activate mast cells. Capsaicin-induced depletion of sensory nerves prevents the neuropeptide release and inflammatory skin responses like the flare. Sensory nerves can be stimulated under pathological conditions by proteinases via activation of proteinase-activated receptors (PARs), by protons through interaction with acid sensing ion-channels (ASICs) or by the transmitter substance acetylcholine which is produced and released from keratinocytes and interacts with nicotinic and muscarinic receptors. Stimulation of nerve fibres is followed by release of e.g. neuropeptides that further affect many target cells in the skin including inflammatory cells like mast cells, leukocytes and neutrophils. This interplay between neuronal and non-neuronal cells in the skin is important for skin homeostasis and the imbalance in this system may be involved in skin diseases like psoriasis and atopic dermatitis.

Dr J A Cotterill, Leeds, UK Should dermatologists create imposters?

What are the emotional, psychological and psychiatric consequences of producing a cosmetic imposter?

Should we as dermatologists be party to cosmetic surgery in prepubertal children?

Is it morally right to removal normal skin for cosmetic purposes?

Is it necessary to look good to feel good?

Why do so many people look to cosmetic dermatology and surgery to resolve their problems, particularly those with low self-esteem?

What is the pathogenesis of low self-esteem?

Ralph M. Trüeb, Department of Dermatology, University Hospital of Zurich, Switzerland

Many patients with a hair or scalp disorder have psychological issues associated with their chief complaint. Most psychocutaneous conditions can be grouped into (1) psychophysiologic disorders in which the scalp disorder is exacerbated by emotional factors, e.g. seborrheic scalp dermatitis, (2) primary psychiatric disorders in which there is no real skin condition, but everything seen is selfinduced, e.g. trichotillomania, neurotic excoriations, factitial dermatitis, (3) cutaneous sensory disorders, in which the patient has various abnormal sensations of the skin with no primary dermatologic lesions and no diagnosable internal medical condition responsible for the sensations, e.g. scalp dysesthesia, and (4) secondary psychiatric disorders, in which patients develop emotional problems as a result of hair loss, usually as a consequence of disfigurement. Patients with psychocutaneous disorders are often reluctant to be referred to a psychiatrist, and the dermatologist is then the physician designated by the patient to handle the chief complaint. To handle these cases effectively, the dermatologist must be capable to diagnose and classify psychocutaneous disorders and select the appropriate class of psychopharmacologic agent as indicated. Finally, the best way to alleviate emotional distress caused by hair loss is to effectively treat it: The intensity of the distress that the patient expresses should influence the clinician’s decision to treat the hair disorder. For example, the decision to use finasteride in a male patient with a borderline clinical state of androgenetic alopecia may hinge on the amount of distress the patient suffers from his hair loss.

Brosig, B., Gieler, U., Euler, S., Brähler, E.

W. Milch, Giessen

The experience of having a skin is one of the most profound bodily experiences which is deeply connected to the experience of the other and the me. The self as a psychic structure organizes these self-experiences and gives us a feeling of coherence and continuity. It can be conceptualized as an independent centre to initiate, organize and integrate the motivational systems and the experience. In the course of treatment, this aspect can be experienced in the intersubjective relation between patient and physician. Psychopathologically psychosomatic skin-symptoms can be understood as disorders of self-regulation which concern a self-state or a body-state (physiological function). The pathologic selfregulation has its origin in the interactional regulation with a lack of inner regulating structures (representations) and/or objectmodulators (selfobjects). To understand self-regulation, the psychobiological regulation of affect, attachment, and disturbances of intersubjectivity will be discussed. Selfpsychologically oriented treatments of psychosomatic patients focus on self-regulation in the intersubjective treatment-process (e.g. by selfobject transferences). Selfpsychological concepts to treat psychosomatic patients are demonstrated following 5 treatment-principles.

M.Musalek*, U.Mossbacher**, H.Poppe*, R.Mader*, I.Obermann*, P.Pichler* * Anton Proksch Institute Vienna

** Department of Dermatology, Medical University of Vienna

In clinical dermatological practice we may find all kinds of mental disorders and psychic problems. Reviewing literature one might get the impression that the most common psychopathological features are due to so-called somatoform disorders (e.g. chronic itching, glossodynia, chronic pain syndromes, etc.), phobias and delusions (acarophobia, Aids-phobia, delusions of parasitosis, etc.), and personality disorders resulting in various forms of self-mutilitation and self-destruction. As it could be shown by a recent study carried on 500 dermatology patients by professional psychiatrists in two Dermatology Clinics in Vienna, depression and anxiety disorders were the most frequent mental disorders to diagnose. Many of the cases of depression were not at all recognized by the dermatologist. Also the various forms of substance abuse and dependence, e.g. alcohol dependence, tranquilizer abuse, etc., are relatively seldom diagnosed in dermatological practice in comparison to their frequent occurence. As depressions and all forms of substance dependence remain the most overlooked psychopathological features in dermatological in-patients and out-patients, the main focus in this presentation will be the improvement of (early) recognition of these disorders.

Angelo Picardi - Dermatological Institute IDI-IRCCS, Rome

A relationship between psychological factors and skin diseases has long been hypothesised. Indeed, the skin is responsive to emotional stimuli and plays a pivotal role as a sensory organ in socialisation processes through the life cycle. Also, its appearance influences body image and self-esteem. Further, the skin and the central nervous system are embryologically related and share several hormones, neurotransmitters, and receptors. Research findings support the common opinion that the mind can affect the skin. Several studies found an association between certain skin diseases and stressful events, reduced social support, and personality characteristics related to impaired emotion regulation. Also, case reports and clinical experience suggest that some cases of skin diseases might represent a complication of a psychiatric disorder. Causality might also flow from the skin to the mind, and psychiatric disorders may result as a complication or a consequence of skin disease, in reaction to disfigurement, perceived social stigma, or undesirable lifestyle changes. Indeed, some studies suggest that perceptions of stigmatisation contribute to disability and reduced quality of life in patients with skin diseases, and that the risk of developing psychiatric complications is increased in dermatological patients who do not improve with dermatological treatment. The prevalence of psychiatric and psychological conditions among dermatological patients has been the subject of many investigations. Psychiatric disorders were found to be frequent, and particularly high prevalence estimates have been observed among patients with lesions on exposed body parts, especially women. The most frequent psychiatric disorders are depressive and anxiety disorders, while adjustment and somatoform disorders are also commonly observed. Psychiatric morbidity is a source of concern not only because it causes substantial suffering and disability, but also because it has been found to be associated with lower scores on skin-specific health-related quality of life instruments and with poor medication adherence. As in other medical specialties, the classical psychiatric classification might be usefully supplemented by psychosomatic diagnostic criteria specifically developed for use in medical diseases. It has been found that conditions such as demoralisation, health anxiety, irritable mood, Type A behaviour are prevalent in dermatological patients and are independently associated with psychological distress and impaired quality of life. Although the dermatologists’ awareness of the problem is rising, several studies suggest that psychiatric disorders still go often unrecognised and are believed to be less frequent than they actually are in many skin conditions. Some self-completed screeners for depression or general psychiatric morbidity have been specifically validated in patients with skin disease, and they might be useful due to their brevity, acceptability, and ease of administration and scoring. Educational programs aimed at increasing dermatologists’ awareness of mental health issues and promoting the use of psychiatric screening questionnaires might help increase recognition of psychiatric morbidity in patients with skin disease. In conclusion, evidence is accumulating that the relationship between psychological factors and skin disease is complex and mutual. These research findings highlight the need for a biopsychosocial approach to patients with skin disease.

Sylvie G. CONSOLI

7 rue Mouton Duvernet 75014 Paris, France.

Excessive natural or/and artificial tanning has now become a true form of risk-taking. This at risk-behavior is favored by values conveyed by contemporary western media and by the highly lucrative industry linked to tanning salons. But, above all, excessive tanning, which is common among adolescents and young adults, is favored by psychological factors that are prevalent in this age range (particularly narcissistic insecurity). Such a behavior is a concern for dermatologists whose opinions and advice are valued by patients, the media and health care professionals planing information and prevention campaigns.

John de Korte

Department of Dermatology, Academic Medical Centre, University of Amsterdam - Amsterdam, The Netherlands

Health-related quality of life reflects patients’ subjective evaluation of the impact of disease and/or treatment on their physical, psychological, social functioning, and well-being. It is a comprehensive construct, especially relevant in the study and management of diseases affecting patients’ daily lives. The number of studies in which quality of life is being used as one of the outcome measures is rapidly growing. These studies give an insight into the interventions being used to improve quality of life, the measures being applied to assess quality-of-life outcomes, and the degree of improvement these interventions are able to accomplish. Several quality-of-life outcome studies have been conducted at the Department of Dermatology of the Academic  Medical Centre of the University of Amsterdam, including a randomized controlled trial with systemic drugs, a clinical investigation of a diseasemanagement programme, and a systemic literature review of the quality-of-life studies. On the basis of these studies the following issues will be discussed in a didactic presentation:

1) the relevance and applications of quality of life in chronic skin diseases,

2) the state of the art of quality-of-life research in chronic skin diseases, and

3) the state of the art of quality-of-life outcomes research in chronic skin diseases.

Jacek C Szepietowski

Department of Dermatology, Venereology and Allergology, University of Medicine, Wroclaw, Poland

Background: Pruritus is an unpleasant cutaneous sensation which provokes the desire to scratch. For patients it is usually much worse than pain.

Objectives: The aim of this presentation is to give, based on literature and own experience, an overview of pruritus as the itching complex, paying special attention to stress, quality of life and treatment modalities.

William M. Gould, 750 Welch Road, Suite 218, Palo Alto, California 94304

In dermatology, as in all of medicine, psychological factors are present in every doctor-patient interaction. Thus, there is a need to teach this subject to medical students and to dermatology residents. However, there are some curious things about psychological medicine. First, we don’t seem to agree on the name of the subject. Is it psychocutaneous medicine, psychodermatology, or psychosomatic dermatology? Second, patients, and not a few physicians, have personal ambivalent feelings about this area. Third, the dualistic view prevalent in Western thought keeps the two entities of mind and body separate and distinct. We have difficulty grasping and understanding that both physical and psychological factors are important in health and in disease. Effective training in dermatology is accomplished by having the young physician work side by side with an experienced practitioner. This is as true for the psychological parts of dermatology as it is for basic clinical dermatology, dermatopathology, and dermatologic surgery. In the past, lectures, readings, and liaison clinics have been methods for teaching psychological medicine. While each of these has merit, nothing is as effective as direct patient care under the supervision of a skilled mental health professional. Every training program in dermatology should have a mental health professional who is physically present and integrated into the dermatology department for the entire period of resident training.

Andrea W.M. EVERS, Elisabeth L.M. VERHOEVEN, Piet DULLER, Peter C.M. van de KERKHOF, Floris W. KRAAIMAAT

Radboud University Medical Center Nijmegen, Department of Medical Psychology 118, PO Box 9101, NL- 6500 HB Nijmegen, The Netherlands

Objective: Itching is a problem frequently seen in patients with skin diseases, leading to habitual scratching, fatigue, restlessness, worsening of skin problems and reduced quality of life. Methods: Data from three research projects with different methodologies and study populations are presented on the prevalence, psychological determinants and therapeutic possibilities for complex itching problems in patients with skin diseases. Results and conclusions: A large population-based study with 12,000 patients in general practices shows that itching is a frequent complaint in various skin diseases, particularly chronic skin diseases like atopic dermatitis and psoriasis. Secondly, crosssectional studies on the chronic skin diseases of atopic dermatitis and psoriasis at dermatological clinics indicate that cognitivebehavioral factors, such as chronic scratching and stress problems, play a prominent role in the maintenance or worsening of complex itching problems. Finally, data is presented on cognitive-behavioral treatments geared to improving patients’ ability to cope with itching and scratching in chronic skin diseases. In particular, a multidisciplinary group treatment designed to improve the ability to cope with itching and scratching in patients with atopic dermatitis was studied in a controlled trial, demonstrating effects on improved skin status, itching and scratching and health-related quality of life.

Yoko Kataoka MD

Department of Dermatology, Osaka prefectural medical center for respiratory and allergic diseases, Japan

Suffering from chronic disease is a risk factor for depression. As in dermatology atopic dermatitis is one of the commonest chronic diseases, atopic dermatitis patients are supposed to have risk of depression. On the other hand, in our clinical experiences exacerbations of atopic dermatitis were sometimes seen followed by onset of depression. To clarify the relationship of dermatitis activity and depressive status, atopic dermatitis patients in our hospital which is one of the largest institutes for atopic dermatitis in Japan were retrospectively reviewed for these 8 years. The subject was defined that atopic dermatitis patients over 15 years old who were followed by the author because the accurate diagnosis of depression was difficult for untrained other dermatologists. The diagnosis of depression was based on DSM-. There were 29 patients (male: female=9: 20, 16~64 years old of age, the average age was 26.4 years old.) who were complicated with depression among 1000 patients of adult type atopic dermatitis. 22 patients were supposed to fall into depression after some life events, 7 patients were considered to fall into it in the course of longstanding uncontrolled severe atopic dermatitis. In the former group skin symptoms of 19 patients were aggravated with the onset of depression, 1 patient improved, and 2 patients unchanged who fell into depression in the following years after remission of previous severe atopic dermatitis. After getting improvement of depressive status of 26 patients who were able to be followed, skin symptoms of 17 were improved, 2 aggravated, 3 no change, 4 now still on treatment. These results show that complication of depression is an aggravating factor of atopic dermatitis. Depression is known as a systemic disorder not only of mood but also of endocrine and autonomic nervous system. Immunological disorders in depressive status are also pointed out in recent papers. Several mechanisms are presumed to induce the aggravation of atopic dermatitis in depressive status. Once the dermatitis aggravated, depressive patient more suffers falling into the vicious circle of dermatitis and depressive disorder. Dermatologists should be aware of depression as a complication and also an aggravating factor of atopic dermatitis.

Martin Steinhoff, M.D., Ph.D., Dept. of Dermatology, IZKF Münster and Ludwig-Boltzmann Institute for Immunbiology of the Skin, University Hospital Münster, Münster, Germany

The cutaneous nervous system regulates a variety of physiological and pathophysiological conditions such as cellular development, growth, differentiation, tissue repair immunity, inflammation, pruritus, pain, and burning. Several structures and cells are involved including cutaneous nerve fibers, which release neuromediators and activate specific receptors on resident target cells or transient immune cells in the skin. Cutaneous neuromediators include different biochemical entities. Classical neurotransmitters such as catecholamines and acetylcholine are released from the autonomic nervous system or cutaneous cells to modulate inflammatory or immune functions in the epidermis and dermis via high-affinity receptors. Neuropeptides such as substance P, calcitonin generelated peptide (CGRP), vasoactive intestinal peptide (VIP), somatostatin or proopio-melano-corticotropins (POMC) peptides, for example, can be released from both sensory or autonomic nerve fibers to activate a variety of cutaneous cells through high-affinity neuropeptide receptors or by direct activation of intracellular G protein signalling cascades. Proteinases such as tryptase or neutral endopeptidase, for example, inactivate neuropeptides in the extracellular space or at the cell surface thereby terminating neuropeptide-induced inflammatory or immune responses. Proteinase-activated receptors (PARs) or transient receptor potential ion channels of the vanilloid type (capsaicin receptors) are recently described receptors which may have a high impact in regulating cutaneous neurogenic inflammation. Upon stimulation by exogenous (irritation, UV-light, microbes) or endogenous (“stress”, hormones, mediators) factors, sensory nerves become activated thereby transmitting the stimulus via afferent fibers to the central nervous system. Additionally, nerve endings of these fibers respond to an axon reflex in the periphery resulting in the release of

neuropeptides. Neuropeptides bind to high-affinity receptors on target cells leading to plasma extravasation, edema, immunomodulation and epithelial cell activation (neuroinflammation). Vice versa, “stress factors” can modulate the hypophyseal-adrenal axis resulting in the release of factors which modulate immune cells in the periphery (e.g. glucocorticoids, noradrenaline, macrophage-migration inhibitory factor). These factors directly modulate immune cells of the adoptive and innate immune system thereby regulating immunity. Together, a close multidirectional interaction between neuromediators, high-affinity recetors and regulatory proteases on nerves, cutaneous cells and transient or permanent immunomodulatory cells are involved to maintain tissue integrity and regulate inflammatory responses in the skin. Thus, psychological and nerval factors may directly modulate neuroimmunological responses in skin diseases such as atopic dermatitis, psoriasis, urticaria and rosacea, for example.

Gerhard Schmid-Ott (1), Thomas Werfel (2), Joerg Kupfer (3), Uwe Gieler (4) and The German Atopic Dermatitis Intervention Study (GADIS) study group

(1) Department of Psychosomatic Medicine, Hannover Medical School, 30625 Hannover, Germany

(2) Department of Dermatology and Allergology, Hannover Medical School, 30449 Hannover, Germany

(3) Department of Medical Psychology, Justus-Liebig-University, Giessen, Germany

(4) Department of Psychosomatic Medicine, Justus-Liebig-University, Giessen, Germany

Objectives: To study the effects of age-related, structured atopic dermatitis (AD) educational programmes on the management of AD in children and adolescents.

Methods: Standardized AD group intervention programmes were developed by a National Study Group to educate parents of AD children aged 3 months to 7 years (Group 1), parents and their AD children aged 8–12 (Group 2), and AD adolescents aged 13–18 (Group 3). After randomization to ‘intervention’ or to ‘no education’, parents and/or children in the intervention groups took part in six group sessions weekly, each lasting 2 hours. Efficacy was evaluated using the SCORAD and standardized psychometric questionnaires. In programmes for the management of AD in children under 13 years of age, the German questionnaire ‘Quality of life in parents of children with atopic dermatitis’ was also given. Itching behaviour was measured with the ‘JUCKKI’ for children aged 8–12 and the ‘JUCKJU’ for adolescents aged 13–18. The two factors of the questionnaires cover the areas ‘catastrophization’ and ‘coping’. The changes in the parameters investigated at the beginning of the study (T0) and 12 months after the end of the education programme (T1) were analysed using analyses of covariance.

Results: In all age groups, significant improvements in SCORAD severity AD were seen in the intervention groups when compared with the control groups. Parents of AD children under 7 years old experienced significantly better improvement in all five quality of life (QoL) questionnaire subscales (‘psychosomatic wellbeing’, ‘effects on social life’, ‘confidence in medical treatment’, ‘emotional coping’, ‘acceptance of the disease’), while parents of AD children aged 8– 12 years experienced significantly better improvement in the last three of the quoted QoL subscales. Regarding itching behaviour, ‘catastrophization’ and ‘coping’ in children aged 8-12 showed significantly greater improvements in the intervention group; in adolescents, only subscale ‘catastrophization’ showed a significantly greater improvement.

Conclusions: The results of the study suggest that the educational programmes for the parental management of AD in children and self-management of adolescents should be integrated into routine care.

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2. Symposia

1Department of Dermatology, Venereology and Allergology, University of Medicine, Wroclaw, Poland

2Department of Dermatology, University of Wales College of Medicine, Cardiff, UK

3Department of Dermatology and Venereology, University of Medicine, Bialystok, Poland

4PharmacoEconomics & Quality of Life Programmes, Pierre Fabre SA, Boulogne- Billancourt, France

Background: Quality of life is a very important parameter. Unfornunatelly, in Poland there were no tools available for measurement the quality of life of dermatological patients. The Dermatology Life Quality Index (DLQI) is a scale devised to evaluate the impact of dermatological diseases on the life of patients.

Objective: The aim was to create a validated version of the DLQI in Polish.

Material and methods: Following international methodological recommendations (forward translation, quality control, backward translation and a pilot test) the DLQI questionnaire was translated from its original English into Polish. Sixty four volunteers with dermatological diseases were asked to comlete the questionnaire twice with an interval of 14 days. The reproductibility of the Polish version of DLQI was assessed with the Intraclass Correlation Coefficient (ICC). The internal consistency of the scale was evaluated by calculation the Cronbach’s coefficient.

Results: A pre-test demonstrated clarity and understandability across social classes and ages. A preliminary test-retest comparison of the final scale showed satisfactory reliability (ICC = 0.56) and good internal consistency of the Polish version of DLQI score (Cronbach α = 0.90).

Conclusions: The DLQI scale, one of the most widely used tools for assesing the impact of dermatological diseases on the life of patients, can now be widely used in Poland.

Jacek C SZEPIETOWSKI1, Adam REICH1, Przemysław PACAN2, Emilia GARLOWSKA3, Eugeniusz BARAN1

1Department of Dermatology, Venereology and Allergology, University of Medicine, Wroclaw, Poland

2Department of Psychiatry, University of Medicine, Wroclaw, Poland

3Novartis Pharma, Warszawa, Poland

Background: Onychomycosis is the most frequent nail disease, which could impair the patient’s quality of life.

Objective: The presented study was undertaken to evaluate the impact of toenail onychomycosis on quality of life among Polish population.

Material and methods: 3904 (2269 females and 1635 males) individuals fulfilled an international onychomycosis-specific quality of life questionnaire consisting of statements regarding social, emotional and symptoms problems. All patients had toenail onychomycosis confirmed by the positive direct microscopic examination and/or by the positive mycologic culture. 767 patients suffered simultaneously from fingernail onychomycosis. All patients were divided into subgroups according to sex, age, education level, place of living, type of onychomycosis, number of involved toenails, fingernails involvement, duration of illness and previously used antimycotic therapy.

Results: Most of the patients demonstrated significantly reduced quality of life. The degree of life impairment varied between analyzed subgroups. Patients with more advanced toenail onychomycosis and with fingernail involvement were more seriously affected. Both social and emotional impairments were more pronounced in females than in males, although there were no differences according to symptoms. Moreover, patients with better education level and people living in towns or cities were more emotionally and socially affected by onychomycosis, although people living in the country or with poorer education level presented with significantly more severe symptoms.

Conclusions: Toenail onychomycosis is still a serious medical problems, which can significantly reduce the patient’s quality of life.

Liana MANOLACHE, Vasile BENEA

Purpose: Three groups of patients with alopecia areata, lichen planus, vitiligo were compared regarding some psychosomatic aspects (stress involvement, anxiety).

Patients and method: 72 patients with alopecia areata, 38 patients with lichen planus, 54 patients with vitiligo (matched with controlgroups of patients with skin diseases not related to stress); Life Events and Difficulties Scale (Holmes and Rahe), Hamilton Anxiety Scale (HAS) were used.

Results: Mean age was around 20 years old for alopecia areata and vitiligo and around 45 years old for lichen planus. For children with alopecia areata and vitiligo, monoparental family seems to be a risk factor (more than 20% of cases). Stressful events appear in 60% of vitiligo patients, and in more than 75% in cases of alopecia areata and lichen planus. In control groups there were stressful events in 20% of cases. Odds ratio were: 12.5 for alopecia areata, 12.1 for lichen planus and 6.15 for vitiligo. In most than ¼ of cases of lichen planus the stressful event was represented by someone’s dear illness. 1/3 of vitiligo patients mentioned death of a close relative as stressful event. Beginning/ finishing school or exams were most vulnerable periods for children with alopecia areata and vitiligo. Family problems (disputes, financial problems, deaths or new members) and job problems (changing conditions or responsibilities, dismissing ) were more frequently noticed by adult patients with these psychosomatic diseases. Adult patients had medium HAS scores in 40% of vitiligo cases, 50% of lichen planus cases and in 70% of alopecia areata patients.

Conclusions: In all three diseases, stress seemed to play an important role at the onset or in aggravations. Most important events were related to the family’s matters (illness, death, separations, discussions etc.). Adult patients are more anxious, anxiolytic drugs being useful reducing the worries and improving their estate.

Jecht, E.W., Schmid-Ott, G.

We compared 324 patients suffering from Psoriasis (PP) with 363 patients suffering from vitiligo (VP). Both groups were analyzed on the basis of their scores in the "Questionnaire on Experience with Skin Complaints" (QES). In addition, VP were compared to a representative group of PP drawn from the handbook of the "Marburg Skin Questionnaire"  (MSC). Statistically significant higher values were found for PP in most subsections of both the QES and the MSC. No difference, however, was seen for the subsections "composure" (QES) as well as "helplessness" and "anxious-depressive mood" (MSC). Against this background, we will examine the significance of stigmatization.

Adam REICH, Danuta NOWICKA, Jacek C SZEPIETOWSKI

Depatment of Dermatology, Venereology and Allergology, University of Medicine, Wroclaw, Poland

Background: Androgenetic alopecia is the most common alopecia of all, comprising about 95% of cases. This ailment could negatively influence patients well-being.

Objective: The aim of the study was to evaluate the influence of androgenetic alopecia on quality of life among young men.

Material and methods: One hundred and ten young men, aged between 21 and 35 years (mean 24.2±3.2 years) were included into this study. Every person was carefully investigated in order to detect androgenetic alopecia. Then the patients were asked to answer the 10 questions of the Polish version of Dermatology Life Quality Index (DLQI). The results were statistically analysed with Mann Whitney U test and Fischer’s exact test.

Results: The symptoms of androgenetic alopecia were stated in 26.4% men: 16.4% persons presented with stage 1 of alopecia, 8.2% with stage 2, and 1.8% with stage 3. The mean time of alopecia appearance was 22.4±4.5 years, and the mean duration of the disease was 4.2±1.8 years. Patients suffering from androgenetic alopecia demonstrated significantly reduced quality of life according to DQLI compared to subjects with normal hair pattern (2.96±3.33 and 0.57±0.92, respectively; p<0.001).

Conclusions: Based on the presented results it could be stated that androgenetic alopecia negatively influence patient’s quality of life and can be a serious psychosomatic problem for selected subjects.

Florence DALGARD, Institute of General Practice and Preventive Medicine, University of Oslo, Norway

Lars LIEN, Institute of General Practice and Preventive Medicine, University of Oslo, Norway

Ingvild DALEN, Institute of Basic medical Sciences, Department of Biostatistics, University of Oslo, Norway

Background: Itch is a symptom common to several chronic skin diseases and frequently encountered in the dermatological consultation. Unlike other dermatological visible symptoms itch is subjective and often challenging for clinicians.

Objective: The aim of this study was to explore the relation between itch and negative life events in the general population.

Materials and Methods: The method used was a questionnaire on self- reported skin complaints. It was previously developed and validated. The design of the study was cross sectional. 40 888 in the city of Oslo, in age groups 30, 40, 45, 60 and 75 received a postal questionnaire. It included questions on self- reported health, and psycho-social factors as mental distress, negative life events and social network. 18 770 responded, thereby obtaining a response rate of 46%. A non responder study has been conducted.

Summary of Results: In this urban population the prevalence of itch was 7,5% among men and 9,2% among women. Both men and women having experienced any negative life event in the course of the last 6 months reported more itch. Men having serious economical problems or problems with the police reported more itch (16.4%) and women being dismissed from their job or having serious economical problems reported more itch (18.4%).

Conclusion: This study showed that the symptom itch is common in the community and that there is a strong association between self-reported itch and negative life events in the general population.

These findings should be retained in the dermatological consultation.

1Osaka Police Hospital, Osaka JAPAN,

Atopic dermatitis is a chronic skin disease that has a psychosomatic aspect. Its aspect becomes one of major problems in Japan. Clinical and epidemiologic studies have demonstrated that psychosocial factors affect the symptoms and course of atopic dermatitis. However, most Japanese dermatologists do not have any knowledge of psychosomatic approach. Psychosomatic aspect in atopic dermatitis has three categories: (1) psychosocial stress induces or aggravates atopic dermatitis; (2) the illness of atopic dermatitis itself induces psychosocial function; (3) therapeutic compliance of atopic dermatitis is disturbed by characteristic or psychosocial factors. We proposed a guideline for the psychosomatic diagnosis and treatment of atopic dermatitis. This guideline is composed of diagnostic chart, psychosomatic scale for atopic dermatitis (PSS-AD) and therapeutic chart. First, we estimated the validity of PSS-AD. PSS-AD was performed to 111 atopic dermatitis patients. Factor analyses lead three subcategories described above. In 50 patients, evaluation of psychosomatic aspect was used with both PSS-AD and clinical examination by a certified psychodermatologist. The sensitivity was 69% and the specificity was 63%. We have distributed the guideline to 978 dermatologists practicing in some part of Japan, and investigated the usefulness and the importance. The results of the investigation showed that it was important and useful for them to learn psychosomatic approach for atopic dermatitis but was hard to practice the approach in a-fewminutes regular examinations.

Judith Anna BAHMER, Julius KUHL, Friedrich A. BAHMER

In chronic skin diseases such as Psoriasis, Atopic Dermatitis, and Urticaria psychological factors play an important role for onset, exacerbation and duration of disease. While the effects of these diseases on well-being and quality of life are well known, little research has been carried out on disease-provoking and diseasemaintaining psychological factors. Here we present the results of an empiric psychological study with 56 patients, suffering from Psoriasis, Atopic Dermatitis, and Chronic Urticaria. On the basis of a computerized questionnaire (“Therapy Accompanying Personality Diagnostic Instrument”; Kuhl J, 2001), factors like needs and goals, somatic complaints, emotional state, thoughts and ways of stimulus perception, affect regulation and action control were assessed. With this instrument, relevant differences between the groups were found with some overlap between Atopic Dermatitis and Urticaria. Psoriasis patients, however, differed considerably in a large number of factors, both from patients with Atopic Dermatitis as well as Urticaria. Up to now, patients with psoriasis are trained in secondary prevention programs developed and validated for patients with Atopic Dermatitis. This type of training does not take into consideration the profound psychological differences between patients with Atopic Dermatitis and Psoriasis found in our study. Thus, we designed a holistic medical and psychological training program tailor-made for the needs of patients suffering from Psoriasis.

Laurent MISERY, Sylviane TOUBOUL, Sylvie CONSOLI, Nathalie FETON-DANOU, Fabienne CARDINAUD, Danièle POMEY-REY, Sabine DUTRAY, Silla CONSOLI and the French Group of Psychodermatology

Objective: Stress is known to be associated with flares of seborrheic dermatitis. Nonetheless, no clinical study confirms this idea. We tried to provide data on this topic.

Andrea W.M. EVERS, Elisabeth L.M. VERHOEVEN, Piet DULLER,

Peter C.M. van de KERKHOF, Floris W. KRAAIMAAT Radboud

University Medical Center Nijmegen, Department of Medical Psychology 118, PO Box 9101, NL- 6500 HB Nijmegen, The Netherlands

Objective: Itching is a problem frequently seen in patients with skin diseases, leading to habitual scratching, fatigue, restlessness, worsening of skin problems and reduced quality of life.

Methods: Data from three research projects with different methodologies and study populations are presented on the prevalence, psychological determinants and therapeutic possibilities for complex itching problems in patients with skin diseases.

Results and conclusions: A large population-based study with 12,000 patients in general practices shows that itching is a frequent complaint in various skin diseases, particularly chronic skin diseases like atopic dermatitis and psoriasis. Secondly, crosssectional studies on the chronic skin diseases of atopic dermatitis and psoriasis at dermatological clinics indicate that cognitivebehavioral factors, such as chronic scratching and stress problems, play a prominent role in the maintenance or worsening of complex itching problems. Finally, data is presented on cognitive-behavioral treatments geared to improving patients’ ability to cope with itching and scratching in chronic skin diseases. In particular, a multidisciplinary group treatment designed to improve the ability to cope with itching and scratching in patients with atopic dermatitis was studied in a controlled trial, demonstrating effects on improved skin status, itching and scratching and health-related quality of life.

LVOV A.N. M.D., Ph.D. - Dermatological Department of Moscow

Medical Academy I.M. Setchenov, Moscow, Russia.

Factitious dermatoses are based on primary psychopathological disorders. In spite of this patients suffering from these diseases almost always apply to the dermatologists. In these cases it is especially difficult to diagnose a correct form of a disease. In our clinic we have analyzed a seven-year management experience of self-inflicted and delusional dermatoses. 348 patients were examined; men – 99, women – 249 (mean age 34±2,6 year old). The following conditions were diagnosed: artificial dermatitis– 48, neurotic excoriations – 146, acne excoriee – 109, trichotillomania – 24, onychophagy – 3, delusional dermatosis – 18. In the most patients severe forms of disease predominated, namely ulcers, scars and widespread excoriations (also in the face region). The diagnoses of psychic disorders included the spectrum of affective, neurotic (obsessive-compulsive), schizotypic and delusional disorders. A percentage of diagnostic mistakes by primary dermatological examinations in other clinics was 89,3%. Self-inflicted and delusional dermatoses imitated the following diseases: cutaneous vasculitis, pyodermia ulcerosa, tuberculosis cutis, deep mycoses, pemphigus vulgaris, leprosy etc. Sometimes patients were falsely treated with corticosteroids and cytostatic agents. In our clinic patients were managed in a cooperation of dermatologists and psychiatrists. The anamnesis was noticed to contradict the clinical manifestations. Eruptions were localized on a face, upper and lower limbs, but never on a back. Distinct edges, specific and queer contour (e.g. streaks of caustic substances) were common for lesions, which were often presented as secondary elements of rush. A surrounding skin was usually intact. As a result of 6-8 weeks therapy with the modern neuroleptic drugs (risperidone, olanzapine, quetiapine) a mental condition of patients has significantly improved and self-injuries have ceased. Skin lesions healed totally up. Casuistic reports and treatment results are illustrated in more than 80 original slides.

Adam REICH, Joanna MAJ, Ewa PLOMER-NIEZGODA

Department of Dermatology, Venereology and Allergology, University of Medicine, Wroclaw, Poland

We present 3 cases of dermatitis artefacta to point out the large spectrum of the possible skin lesions and to underline difficulties of the differential diagnosis of this entity.

Case 1. A 32-year-old woman was admitted to the department because of multiple round erosions and small ulcerations localized on the anterior surface of the right thigh. Four years earlier, during pregnancy, Clark III melanoma on the right thigh was diagnosed in the presented patient. The tumour was radically removed. On the examination, the skin lesions were distributed very regularly, each lesion was found in the distance of about 1 cm from other lesions, and the area of lesional skin was laterally very well demarcated from the healthy skin. As skin lesions were also considered to be a metastases of previous melanoma, a skin biopsy was done. Histologically only a toxic damage of the epidermis with stingy mixed infiltration of the dermis was seen. The diagnosis of dermatitis artefacta was put and occlusions with neutral topical agents were employed. As the lesional skin was not accessible for the patient manipulations, a rapid healing of skin lesions was noted.

Case 2. A 20-year-old woman was admitted to our department with a suspicion of pyoderma gangrenosum. The patient demonstrated two deep ulceration on left thigh and right arm. Histology revealed chronic inflammation. Cyclosporine was started, but after several days of clinical observation of the patient the diagnosis of dermatitis artefacta was put and cyclosporine was changed for placebo. During the treatment significant improvement was observed. Some time later the patient confirmed the she lacerated the lesions herself.

Case 3. A 13-year-old girl presented with multiple, linear, and regularly shaped erosions covered with crusts localized on the face and upper limbs was admitted to our department. More lesions were noted on the left hand, as the patient was right-handed. On the breast some linear scars were also seen. The patient was overweight (BMI=29). No other abnormalities were stated during physical examination. During psychological investigation the patient declared that the reason for self-inflicted lesions was too little attention of her parents who were more concentrated on her younger brother.

1Department of Psychiatry, University of Medicine, Wroclaw, Poland

2Department of Dermatology, Venereology and Allergology, University of Medicine, Wrocław,  Poland

Christa-Maria Höring, Stuttgart Patients with body dysmorphic disorder and/or somatoform disease who consult the dermatologist or- seldom- the psychosomatic specialist, often hesitate to accept the doctor’s recommendation or even feel misunderstood. With the presentation of two short cases of a 42 years old woman and a 40 years old man I will discuss the requirement to establish a first good contact: time, knowledge about countertransference processes and dealing with uncomfortable feelings, about narcisstic personality disorder and some empathic sentences to demonstrate that the grief of the patient is understood. The doctor who wants to give a prescription should prescribe himself interest, tolerance and partience.

Harth W, Hermes B, Nicolai T, Kimmritz J.

Many patients express great concern about disfiguring scars following surgical procedures on the skin. Scar-free surgery is not yet possible. But dermatosurgeons, as well as plastic surgeons, continuously investigate different suturing techniques to obtain the least-visible scars possible. The first description of the intracutaneous suture goes back to Halsted, William Stewart (New York 1852--1922 Baltimore) and is used today in aesthetic surgery in a variety of modifications. In the submersed intracutaneous suture, absorbable sutures are knotted in the subcutaneous tissue and the knot thus submersed. The risk of dehiscence is reduced, since the suture remains in the tissue until it is absorbed. This suture technique - here artistically presented - offers the advantage, in addition to the favorable optical aspect with no puncture marks, that the suture material does not need to be removed. Optimal results can be attained especially in facial and phlebosurgical procedures. In summary our observations show very good scar conditions and long-term results. The patients' fear of conspicuous scars and thus stigmatization can be considerably reduced by routine application of this special suture technique.

Taube, K.-M.

Today, erythromelalgia is differentiated in three types: idiopathic, secondary in internal diseases and finally as resulting from hematological diseases. Attacks of reddening and overheating of the hands and feet .elicited by heat or by physical exertion are accompanied by tormenting and burning sensations. The complaints abate rapidly on cooling, for example with cold water. We are presenting three patients suffering from erythromelalgia. the history is long, consultations with physicians in various specialties led neither to a diagnosis nor especially to therapeutic improvement. The patients suffer greatly and have suicidal thoughts. The causes of the illness and possibilities of psychosomatic intervention are discussed and recommendations for dealing with this disease manifestation given.

Christopher Kenneth BRIDGETT, MA(Oxon) BM BCh FRCPsych

This discussion paper aims to give an overview of the current psychodermatology training opportunities for UK psychiatrists. The logistics of improving existing opportunities will be explored, and recommendations offered for discussion. In the UK Consultation-liaison psychiatry is on the training curriculum for all doctors. For trainee psychiatrists, psychodermatology has however a lower profile compared with other liaisons. Manpower shortages in psychiatry, as in dermatology, also mean opportunities to work in psychodermatology are unusual: training in the sub-speciality is therefore potentially unattractive. The probability also that most psychosocial morbidity associated with skin conditions is to be found not in the hospitals where liaison psychiatrists work, but in general practice, needs to be taken account of. As psychodermatology is largely owned by dermatologists in the UK, those with an interest in the field should continue to foster links with their local psychiatric consultation-liaison ser