Perioral Dermatitis 

The cause of this condition, which involves the reddening of skin and pustular eruptions around the mouth, is unknown. It primarily affects young women.

Preventative measures include the avoidance of fluoridated corticosteroids and harsh soaps and face washing. Topical hydrocortisone cream and systemic tetracycline are often prescribed.

A German study found a predominance among highly motivated career women in their thirties. Another study of eighty patients suggested a typical psychological profile:  they had experienced severe childhood frustration; women in the group tended to perceive partners as idealized father figures who disappointed them. The disease often appeared after failures in a relationship or work.

Psychotherapy has been used effectively in combination with conventional medical therapy. In one study, 90 percent of a group improved with treatment that combined psychotherapy and nonsteroid creams; 72 percent of these had previously been treated unsuccessfully with steroids.

Pruritus (Itching)

(Griesemer Index:  86 percent; Incubation period:  seconds)

This common symptom can occur with a wide variety of skin conditions or alone. It can range in severity from a minor annoyance to a continual torture that dominates life. Itching is so important a symptom that I've devoted a separate chapter (see chapter 13).

Psoriasis 

(Griesemer Index:  62 percent; Incubation period:  days)

Heredity is clearly a factor in psoriasis; just as clearly, emotional factors play a role in triggering episodes and determining severity. Two to eight million people in the United States endure the scaling skin plaques of psoriasis, which may be limited to small areas or generalized over large parts of the body.

Five to 10 percent of psoriasis patients suffer an associated arthritis as well.

Photochemotherapy (a drug is administered then followed by exposure to ultraviolet light) is often effective in psoriasis; steroids, tar pastes, and vitamin A derivatives (retinoids) are also used. Methotrexate is usually reserved for the most severe cases. While often effective, it can cause bone marrow and liver damage.


Good results have been obtained with many of the techniques described here, including hypnosis, psychotherapy, relaxation, and biofeedback. Warmth and sunlight improve affected skin for most (this is standard medical therapy) and should be considered in designing an ideal imaginary environment. Group psychotherapy has proved helpful to some patients, especially in cushioning the impact of the disease. Refer to chapter xx for the latest in the psychological treatment of psychopsoriasis.

Rosacea 

(Griesemer Index:  94 percent; Incubation period:  two days)

This condition, which resembles perioral dermatitis, affects three times as many women as men, typically between the ages of thirty and fifty. It consists of persistent flushing, usually of the face, and an eruption that resembles acne. A more particularly disfiguring form where the nose is enlarged and deformed (rhinophyma) is more common in men:  W. C. Fields suffered from rhinophyma. Rosacea often responds well to antibiotics such as tetracycline.

It would be simplistic to call rosacea prolonged blushing, but some links between the symptom and the common experience are clearly present. Studies have found typical rosacea sufferers to be anxious and vulnerable to feelings of insecurity and inferiority, sensitive to criticism, easily discouraged, shy, and socially ill at ease. Guilt and shame are commonly described by these patients. They seem unusually dependent on the good opinion of others.

Patients studied in depth often describe their disease as a punishment or a safeguard, suggesting the importance of the "anger" and "skin as policeman" tasks. Another repeated theme is having to grow up prematurely, possibly due to the inadequacy or death of a parent or economic hardship. Social or sexual stress often triggers exacerbations.

An attempt to explore underlying emotional factors and a method to modify your response to stressful situations (such as relaxation or hypnosis) are clearly worth a trial in resistant rosacea. Scott described one case in which a woman suffered an eruption of rosacea shortly after the death of a close friend. On the surface, the patient showed little grief; in hypnosis, it was clear that her grief had been stopped by intense jealousy of her more attractive friend, who had stolen her boyfriends in the past. Improvement followed quickly after this issue was out in the open, showing how responsive this symptom may sometimes be.

Sarcoidosis  

This systemic disorder of the immune system has highly variable effects and prognosis. For 30 to 50 percent of people, skin involvement, most commonly around the face, is part of the disorder. Any area of skin can be affected.

The usual medical treatment uses topical, intralesional, or systemic corticosteroids. Antimalarial and immunosuppressive treatments are rarely required for skin involvement alone. Any disease in which the immune system is either overactive or underactive is a potential applicant for psychological techniques.

Scleroderma (Progressive Systemic Sclerosis)

This systemic disease of unknown origin is believed to have an autoimmune basis. This potentially life-threatening disease can involve multiple organs; one variant, Morphea, is limited to the skin. Many treatments have been suggested, but at this point, none has clearly emerged as effective. Physical therapy is important to maintain flexibility and mobility.

Psychological techniques have a potential that remains largely unexplored. The major involvement of the immune system, the use of pain control techniques, and help with motivation and depression are likely applications.

Raynaud's phenomenon is often part of the disorder, and here the psychological techniques have a solid track record. This disorder of circulation can make the entire body, but especially the extremities, excruciatingly vulnerable to cold and the formation of skin ulcers. Both hypnosis and biofeedback are quite effective. Control of blood flow is generally one of the easiest physiological dimensions to take charge of. Images of increased blood flow and of blood vessels opening up to help the flow can be augmented with scenes that would promote those effects. With one woman whose life was hampered by ambivalence and an inability to make commitments, we worked simultaneously on the circulation problems and her ability to "let it flow" more generally. Being able to tune into her emotional "pulse," feeling in touch with her heart, and confronting fears of her passions helped her not only control physical symptoms but live a more "full-blooded" life.

Seborrheic Dermatitis  

(Griesemer Index: 41 percent; Incubation period: days)

In this condition, which resembles dandruff, accelerated growth of skin cells produces red, scaly eruptions of the scalp. The cause is unknown, but stress has been cited as a trigger factor. Involvement can spread to the head and face and even the chest and areas of skin folds. Medical treatment for the scalp includes shampoos containing selenium sulfide, zinc prythione, and tar. For severe scalp symptoms and other areas, the most common treatments are corticosteroids, antifungals, and antibiotics.

There has been little research into emotional factors that may trigger or follow seborrheic dermatitis. Wittkower and Russell found that two-thirds of one hundred patients experienced social difficulty:  they feared ridicule or simply being conspicuous. As a group, they were slow to make friends, but hardworking and perfectionistic. Almost all described triggering incidents that threatened their self-esteem.

The techniques I've described may work in seborrheic dermatitis, but here, more than with many other conditions, you must be your own researcher.


Self-inflicted Wounds (Factitia)

(Griesemer Index:  69 percent; Incubation period:  seconds)


People inflict a wide variety of wounds on their skin: tearing, cutting, freezing, or burning themselves. The wounds may be treated by a physician but their cause is clearly psychological and requires an appropriate approach.

You don't have to be crazy to damage your own skin, although some such self-victims are in fact psychotic. Most are simply acting out in a particularly concrete way the kind of self-destructive impulses that others do more subtly. There are ways in which virtually all human beings treat themselves poorly? They range from the extreme of suicide to self-defeating behavior ("fractional suicides"), such as self-isolation, self-neglect, poor diet, and failure to take medication when indicated.

If you inflict damage to your own skin, don't feel like a freak; what you're doing is a dramatic expression of a near-universal mechanism? but do make a determined effort to get to the bottom of your symptom. The first step is owning up to the action and taking responsibility for it? and regarding yourself and your trouble with the same compassion you'd have for a friend. Shame and humiliation are a natural response but are neither necessary nor helpful. Why flagellate yourself for something you cannot, as yet, fully control?

This advice is also directed to anyone who in any way aggravates a skin symptom, whether by picking or squeezing pimples, compulsively washing hands plagued by dry skin, or rubbing places that are already irritated. Only when you take responsibility for what you're doing can you become an active party in helping yourself.

Any and all the exercises in this book may help you gain insight into the tasks that your skin assaults are seeking to accomplish. Anger, love, and sexuality tasks are likely to be particularly relevant. Self-damage is always a cry for help. It may attempt to atone for an obscure sense of sin:  some people report that they damage their skin with a feeling of purifying themselves, of releasing enormous pressure. It may seem the only way to get special care and nurturance, especially for those whose parents came through only in times of illness or distress.

Don't overlook loyalty as a motive for self-destructive acts. Anyone who treats himself badly was taught to: often we take over the task of chastising ourselves to keep up the work of physically or emotionally abusive parents.

Because the emotional nature of this symptom is particularly difficult to grapple with alone, be ready to seek professional help.


Stigmata and Spontaneous Purpura 

Stigmata are marks that appear spontaneously, usually duplicating the wounds of Christ:  bruises may appear on the forehead, suggesting the crown of thorns; stripes on the back, indicating the weight of the cross; and wide plaques on the hands, corresponding to the nails of crucifixion. However, they also appear in members of other religions, such as Islamic people, while contemplating the battle wounds of Mohammed, for example, and in the nonreligious. Their cause is unknown, and there is no medical treatment. They're a striking example of the interaction of mind and skin.

Perhaps related are spontaneous purpura, or hemorrhages beneath the skin, which often appear after violent dreams or hallucinations. Victims are predominantly female and are usually involved in some sort of emotional turmoil; the phenomenon is most likely to occur in the highly suggestible.

Hypnosis and psychotherapy may help in these conditions. In one woman, pains of the hands and feet, which appeared while she was contemplating the crucifix, disappeared with the help of hypnosis.

Sun Addiction

This is obviously not a skin disease per se but a way of making sure you get one. How times change! Remember the old photographs of the elegant couple, cigarettes in hand, basking in the intense Caribbean sunshine? Yesterday's ultra suave, today's ultra senseless?  (See also "Sun Addiction" in chapter 3.)


Vitiligo 

(Griesemer Index:  33 percent; Incubation period:  two to three weeks)


The cause of this disorder, in which areas of the skin completely lose their normal pigmentation, is unknown, but the immune system may play a role. Topical corticosteroids are sometimes helpful, as is PUVA (oral or topical psoralen and ultraviolet A light). Stains or cosmetics are also used.

Vitiligo causes no pain, physical discomfort, or disability:  it is purely a cosmetic condition, but as such it causes extreme distress. In one study, two-thirds of patients with vitiligo reported embarrassment; one-half said they were socially ill at ease, felt ugly, or dressed inappropriately to hide affected areas. More than one-third said it interfered with their sex life. Two-thirds reported that strangers stared at them; 72 percent said they asked questions and 16 percent said onlookers made rude remarks. A full 40 percent appeared to be chronically depressed by their symptom:  "I hate myself. I feel like a freak" were typical comments.

Higher self-esteem and ego strength characterized patients who coped best with the burden of vitiligo. It appears that a person who generally feels better about himself or herself will better handle the self-image assault and embarrassment of this condition.

One complaint that emerged in patients' reports was their doctors' insensitivity to their needs and problems; they felt they needed more personal interest, encouragement, and support. A patient with vitiligo who feels this way might reflect that those needs are absolutely legitimate but the dermatologist may be ill-equipped, by training and temperament, to satisfy them; psychotherapy can better provide support and foster adjustment to the disease.

One case history reports striking success against vitiligo with hypnotherapy. Gajwani aw Sehgal of Goa, India, described a twenty-seven-year-old woman who had an irregularly pigmented area near the left edge of her mouth for seven years. (In India, the authors note, vitiligo carries a dire social stigma.) She lived in a strained situation with her in-laws and had an unsatisfactory relationship with her husband, whose business activities kept him from devoting much attention to her.

In six sessions of hypnosis (at which she proved adept), it was suggested that her face was flushing and the white spots getting smaller. By the third session, the area had shrunk to half its original size. By the sixth, it had disappeared completely. On the doctor's advice, her husband spent more time with her, following a "prescription" for movies, picnics, and walks. At follow-up, she appeared perfectly healthy.

Generally, the fact that emotions play a triggering role in one-third of vitiligo cases suggests that hypnosis and other psychological therapies may be helpful.


Vulvodynia  

Vulvodynia is chronic vulvar discomfort or pain, especially when characterized by complaints of burning, stinging, or irritation or rawness of the female genitalia.

Vulvodynia is diagnosed when other causes of vulvar pain, such as active yeast infection, herpes, skin disorders, and bacterial infections are ruled out.

Currently there is no cure for vulvodynia. Treatments directed towards symptom relief include drug therapies such as tricyclic antidepressants or anticonvulsants, nerve blocks, interferon, physical therapy, and diet modification. Surgical intervention is an option for some women when more conservative treatments do n ot produce acceptable relief. Psychological techniques such as hypnosis and biofeedback can make a uniquely valuable contribution to treatment.


Warts 

(Griesemer Index (multiple, spreading warts): 95 percent; Incubation period: days)


Warts are benign skin tumors caused by a virus. They are common, particularly between the ages of twelve and sixteen (a British survey found them in 16.2 percent of schoolchildren),67 and usually are removed easily by such dermatological procedures as mild acid, electrocautery, and cryosurgery (freezing). When they recur and spread widely, however, they can be extremely troublesome. See chapter 19 for emotional factors and treatment.

The treatment of warts is the area where psychological techniques have made the greatest inroads into the mainstream of dermatology. Warts seem to disappear and return spontaneously, but their behavior is often linked to emotional factors. The critical factor is likely the immune system, which keeps the virus in check or allows it to flourish.

Human beings have long exploited the emotional sensitivity of warts with a huge arsenal of folk cures. Toads have been sacrificed, cats brought to graveyards at midnight, rituals performed, and incantations sung in efforts to make these growths disappear. There's substantial evidence that such cures work beyond the spontaneous remission rate.

Warts often respond dramatically to simple suggestion; as mentioned, I've had patients report their disappearance after calling me for an initial appointment. Laboratory investigations and clinical trials have shown hypnosis, in particular, to be effective. One group of children, under treatment for other diseases with drugs that suppressed their immune system, were vulnerable to warts that resisted medical treatment. Even here, hypnosis was successful, with the better hypnotic subjects enjoying the best results.

Psychologist Owen Robbins described a young boy who was plagued by severe recurrent warts and by a difficult family situation. His skin cleared quickly after he performed the overdue act of punching his intrusive, overbearing younger brother. I've been impressed by how often warts become a problem for people who are deadlocked in an emotional crisis, a stalemate that must be resolved for life to continue, a general impasse in the process of growing up.

The most effective psychological approach to warts combines hypnotic techniques with exploration of troublesome issues, focused on today's impasse. With insight and life changes that release the patient from his emotional bind, the prognosis, even when warts are severe, is good. Rapport with a doctor who sincerely believes in these techniques is essential. Severe recurrent warts are one of the most frequent reasons people come to see me. Results are particularly favorable.

Warts (Genital or Venereal) (Condyloma Acuminata)

These have a special emotional impact because of the area where they appear?the genitals and around the anus. These warts are the second most common sexually transmitted disease (after Chlamydia trachomatis). They also can increase the risk of some types of cancer.

Topical podophyllum resin is emerging as the treatment of choice. Mild acids, cryotherapy, electrocautery, and laser surgery are all used as well. See chapter xx for the role of emotions and psychological techniques.

Most people with warts find an ideal imaginary environment that incorporates cooling, and perhaps tingling, to be helpful, along with direct suggestions that they disappear. If these measures don't work, try to understand and clear away any possible emotional impasse: headway here often allows hypnotic techniques to become effective.

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