 
E-mail Richard Saltus to share an idea or to comment at Saltus@globe.com
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Mind and Body
Getting under the skinBy Richard Saltus, Boston Globe
This is particularly true of common afflictions like eczema, psoriasis, hair loss, and acne. Most skin specialists say that emotional factors contribute to the fluctuations in severity many people experience with these conditions. Today, more than ever, dermatologists are combining their standard treatments with the tools of psychology, psychiatry, and mind-body medicine in an effort to help patients frustrated by conditions that won't clear up. ``I think psychological factors are an overlay in many conditions, like eczema and psoriasis,'' says Dr. Jeffrey Dover, a dermatologist at the Beth Israel Deaconess Medical Center, adding that psychological measures can help ``the right patient - not every patient.'' The interplay of mind and skin is not a new idea. Even austere medical texts have noted that a patient may be rid of warts by hexing - touching the offending lesions with ``magic'' objects or making other dramatic but meaningless gestures. Warts, say skin specialists, have proved to be the skin lesions most susceptible to mind-body treatments. Some skin conditions are actually caused by psychological disturbances. For example, people who habitually pull their hair out or scratch their skin because they believe they have parasites crawling on them are suffering from known mental disorders. Conversely, some psychological problems are the direct result of skin conditions: A chronic, visible skin disease can cause depression and loss of self-esteem. A chronic skin condition also may result from more subtle psychological factors; the disease may serve a psychic purpose that the sufferer is even aware of. That's when psychotherapy may be especially useful, says Boston psychologist Ted Grossbart, who works with patients to uncover hidden meanings and causes of dermatological disease. Grossbart emphasizes that there is always a biological basis, often an inherited susceptibility, to conditions such as psoriasis and eczema: ``If you don't have that, you won't get the disease,'' he says. But life events and emotional patterns can greatly influence how bad the symptoms are and when they worsen or improve in someone who does have the biological predisposition, says Grossbart, co-author of the book Skin Deep: A Mind/Body Program for Healthy Skin. When frustrated patients come to him, Grossbart explores how fluctuations in their symptoms may be related to life events like promotions, divorce, and unresolved conflicts. For the short term, he may recommend self-hypnosis, imagery, relaxation, and other techniques that might help relieve symptoms. But the long-term strategy is to help people identify underlying problems and learn to ``feel it in their heart, not in their skin,'' he says. One of Grossbart's patients says he believes that during three or four years of therapy he has had fewer flare-ups of the red, raw, flaking skin caused by his chronic psoriasis. The patient says he came to understand how he had been using the skin problem as a means of winning attention and special treatment. Now, he says, ``I've learned to let my skin be skin'' and not a ``political football.'' Few scientific studies document how often such therapy works and for which patients. Grossbart estimates that his strategies yield striking results in one-third of patients, while one-third get some benefit, and the remaining one-third aren't helped. Dr. John Koo, of the University of California, San Francisco, has another approach. A specialist in what he calls psychodermatology, Koo has been a leader in treating skin problems with drugs normally used for anxiety, depression, and other mental disorders. Sometimes, these drugs are aimed at psychological underpinnings of certain skin conditions, but the drugs may even help nonpsychological skin problems such as chronic hives, severe itching, and the pain of herpes infections, says Koo, who is both a dermatologist and psychiatrist. Dermatologists say that many of their patients are reluctant to see a psychologist or psychiatrist. Dover, at Beth Israel, says, ``I give patients the number, but I don't make the appointment for them; they have to want to do it themselves.'' Some skin specialists are skeptical of the mind-skin connection, so whether a particular patient is encouraged to seek psychological counseling depends on what his dermatologist believes. As for the mechanisms that link the mind and the skin, research is only starting to provide some tantalizing clues. For example, the changes in skin caused by stress may be related to hormonal fluctuations in the brain and pituitary gland, says Dr. Richard Granstein, chief of dermatology at New York Hospital. Granstein has done research showing that nerve activity may increase or decrease the activity of the immune system in skin tissue, which might explain some of what patients and their doctors observe. ``There is beginning to be basic scientific evidence that neurotransmitters and nerve endings in the skin do play a role in many skin diseases,'' says Dr. Alan Moshell, a research director at the National Institutes of Health's skin-disease program. ``We may now be seeing a biological basis for things that most practicing dermatologists have accepted for quite a while.''
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