ECZEMA is a chronic skin condition that can be triggered a range of environmental factors. It may come as a surprise that psychological factors can play a huge role too.
Eczema comes in many forms but atopic eczema is the most common. The condition causes the skin to become itchy, red, dry and cracked. People with atopic eczema usually have periods when symptoms are less noticeable, as well as periods when symptoms become more severe (flare-ups). It well understood that coming into contact with certain irritants worsen symptoms, what is less understood is the psychological impact on eczema.
Dr Anthony Bewley, a Consultant Dermatologist at Barts Health (The Royal London Hospital and Whipps Cross University Hospitals NHS Trust), and Honorary Senior Lecturer at Queen Mary University London explains that psychodermatology is a subbranch of dermatology which “champions” the link between the brain and the skin.
“The way that dermatologists see it is that eczema is a genetically predisposed condition,” explained Dr Bewley. Certain stressful life events can trigger these genetic conditions, he notes.
An eczema flare-up can be stressful in itself, explained Dr Bewley: “The visible difference such as the redness, scaling, weepiness, often darkened skin, which gives you a very clear physical difference, but also the persistent itch, is very debilitating because it can keep you awake at night and can make you pretty desperate.”
Despite people’s best efforts to medicate themselves by applying creams, getting a good night’s sleep, and trying not to itch, the symptoms can stubbornly persist.
“People feel completely out of control of their skin, and that’s why they get so desperate and even consider suicide,” said Dr Bewley.
This sense of powerlessness creates a vicious cycle as the stress is likely to trigger the genetic predispositions that give rise to eczema and people may feel more inclined to neglect self-medicating, noted Dr Brewer.
What is the solution?
Psychodermatology takes a holistic approach to treatment, managing the physical disease and the psychological disease simultaneously.
“The physical disease need to be managed with barrier function establishments. That means using lots of good moisturising creams but also it means using anti-inflammatories such as creams or steroids or ultraviolet light treatment, or they can be tablets or even anti inflammatory injection treatments,” said Dr Bewley.
The psychological treatment first and foremost involves engaging patients in a “habit reversal technique,” he explained.
Habit reversal techniques identify the scratching components of atopic eczema and identify a pattern.
Episodes of scratching are often not linear throughout the day and bouts tend to occur at certain times of the day, said Dr Brewer.
“Often before bed or when people first get up in the morning or when they’re on the loo. And if you can identify the times when people are more likely to scratch, then they can replace the habit of scratching the skin with a nondestructive habit such as pinching the skin or grasping a piece of clothing,” he said.
Relaxation techniques also play a pivotal role.
Bewely singles out mindfulness or meditation as particularly effective remedies.
“We know that if you use mindfulness that reduces the inflammatory burden of the skin. But also it assists in the healing of the skin.”
Combining mindfulness with phototherapy – a type of treatment that uses controlled artificial ultraviolet light to help reduce symptoms, can halve the amount of phototherapy that a patient may need, explains Dr Bewely, speeding up the recovery process.
Improved Access to Psychological Therapies or Psychological Treatments IAPT) may also help. These programs are usually six-weekly appointments often via the GP where there will be a focus on anxiety or depression, he said.
“And then other things that we can do is put the patient in the direction of signposting towards patient advocacy groups like the National Eczema Society and they can provide support in terms of psychosocial support,” explained Dr Bewely.
If a patient is feeling so desperate that they’re feeling suicidal, a psychodermatologist will refer them to local psychiatric team.
“We are never afraid to ask that question,” added Dr Bewely.