Management of Psychodermatologic Disorders

Philip D. Shenefelt, MD, MS


Dermatology Nursing 

In This Article

Non-pharmacologic Treatments for Psychocutaneous Disorders


Biofeedback can improve skin problems that have an autonomic nervous system component, such as galvanic skin resistance biofeedback for hyperhidrosis and skin temperature biofeedback for dyshidrosis and Raynaud's syndrome (Freedman, 1989; Sarti, 1998). Hypnosis may enhance the effects obtained by biofeedback (Shenefelt, 2003). Simple stress-reduction temperature-sensing cards are available to measure finger temperature, which correlates with stress. The author finds these simple, inexpensive, and effective. For stress reduction with heart rate variability biofeedback, handheld devices such as the Heartmath emWave Personal Stress Reliever or the Helicor StressEraser are available.

Cognitive-behavioral Methods

Cognitive-behavioral methods alter dysfunctional thought patterns (cognitive) or actions (behavioral) (Levenson, Persons, & Pope, 2000) that damage the skin or interfere with dermatologic therapy. Re sponsive diseases include acne excoriée, atopic dermatitis, factitious cheilitis, hyperhidrosis, lichen simplex chronicus, needle phobia, neurodermatitis, onychotillomania, prurigo nodularis, trichotillomania, and urticaria. Conjuctive use of hypnosis with cognitive-behavioral therapy can facilitate aversive therapy and enhance desensitization and other cognitive-behavioral methods (Shenefelt, 2003).


Hypnosis involves guiding the patient into a trance state of narrowed awareness, focused attention, selective wakefulness, and heightened suggestibility for a specific purpose such as relaxation, pain or pruritus reduction, or habit modification. The hypnotic trance has objectively documented differences from the usual waking state in regional cerebral blood flow (Rainville, Hofbauer, Bushnell, Duncan, & Price, 2002) and EEG (Freeman, Barabasz, Barabasz, & Warner, 2000) patterns. Hypnosis may improve or clear numerous skin disorders such as acne excoriée, alopecia areata, atopic dermatitis, congenital ichthyosiform erythroderma, dyshidrotic dermatitis, erythromelalgia, furuncles, glossodynia, herpes simplex, hyperhidrosis, ichthyosis vulgaris, lichen planus, neurodermatitis, nummular dermatitis, post-herpetic neuralgia, pruritus, psoriasis, rosacea, trichotillomania, urticaria, verruca vulgaris, and vitiligo (Shenefelt, 2000). Hypnosis can also reduce anxiety and pain associated with dermatologic procedures. Hypnoanalysis has been successful with reducing erythema nodosum, herpes simplex reactivation, neurodermatitis, neurotic excoriations, rosacea, urticaria, and verrucae (Shenefelt, 2007).


Mediation produces a relaxing, stress-reducing trance state similar to that of hypnosis. There are many forms of mediation available, including guided meditation recordings for patients new to the process.


Positive expectations can produce positive placebo results, while negative expectations can produce negative nocebo results (Spiegel, 2004). The placebo effect in some common dermatologic conditions such as acne and urticaria is about 30% (Gupta & Gupta, 1996). Disorders higher on the Griesemer scale (see Table 2) are more likely to have a significant placebo effect.


Suggestion used to promote healing, change subjective perceptions, resolve warts, and to reduce pain is as old as language.


Hatha (stretching) or prana (breath) yoga can induce relaxation and thus reduce stress. They should be practiced regularly as a discipline to maintain effectiveness.


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