Archive for General Dermatology

Dr. Neil Alan Fenske receives “The Gustavus Sesquicentennial Award”

Link to

Gustuvas Sesquicentennial Award

video

https://gustavus.edu/alumni/video/

The Gustavus Adolphus College Board of Trustees has established an award in honor of the college’s Sesquicentennial anniversary to recognize individuals who have made a significant difference in the life of the college.

The award, called “The Sesquicentennial Award,” acknowledges and pays tribute to living alumni, parents, friends, and retired faculty and staff who:

Through actions in their personal or professional lives, have advanced the status of Gustavus as a premier liberal arts college; Set a new precedent in the ways they supported and advanced the mission of the college as an institution dedicated to preparing students “for fulfilling lives of leadership and service in society”and/or have brought particular dignity or honor to the college.

On Thursday, February 9th the President of Gustavus Adolphus College, Jack R. Ohle awarded Neil Alan Fenske, MD the Gustavus Sesquicentennial Award.  The presentation and event took place at Malio’s in Tampa.

Neil Alan Fenske, MD is the Professor and Chairman of the Department of Dermatology and Cutaneous Surgery at the University of South Florida, Morsani College of Medicine.   813-974-4744 for appointments

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Bedbugs and You

The common bedbug, Cimex lectularius, is making a comeback.  Transferred by travelers, it quickly sets up housekeeping in bedrooms.  Adults lay eggs in crevices such as in baseboards, walls, and beds.  The nymphs develop through four stages as they develop over one to three months before they become adults.  These nymphs require 10 to 20 blood meal feeds during their development, and the adults also require blood meal feeds.  They generally feed on exposed skin when the person is asleep, piercing the skin with their proboscis mouthparts and actively pumping blood up into themselves.  The bite is painless but redness and itching commonly develop afterwards.  It takes 10 to 20 minutes for the bedbug to become fully engorged with blood.  There is often a series of 2 or 3 bites in a row known as breakfast, lunch, and dinner. Your dermatologist can explain options for reducing the redness and itching that occur after the bites.

Bedbug activity can often be detected by lifting the mattress and looking along the edge of the box springs for little brown bugs about a quarter inch long or brown streaks from their fecal matter. You may see similar fecal streaks on walls or along baseboards. They defecate soon after each meal.  When traveling, it is wise to check the bed and baseboards before settling into the room, even in fine hotels.  Other travelers can transport the bedbugs in their luggage into a room, starting the infestation.  Often only a few rooms are infested in a hotel or motel.  If you stay in an infested room and have your luggage on the floor and open, or if you put clothing in drawers and then back into your luggage, bedbugs may enter and accompany you home. If you have visitors that bring in luggage and stay overnight with you, they can also transport bedbugs to your home.  Bedbugs have become resistant to many common pesticides, so it may cost over a thousand dollars to eliminate these unwelcome visitors from your home.  An ounce of prevention is worth many pounds of cure in the case of bedbugs.

by: Philip D. Shenefelt, M.D. Associate Professor of Dermatology and Cutaneous Surgery at the University of South Florida

Link to Dr. Shenefelt’s Bio: http://health.usf.edu/medicine/dermatology/bios/bio_shenefelt.htm

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Watch out for lime juice or you could get ‘Mexican beer dermatitis’

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Simple treatments help boy’s severe eczema

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THE SUNSCREEN & VITAMIN D DILEMMA: WHATS IS ALL ABOUT?

Sunscreens prevent skin cancer. Some epidemiologic data suggest low levels of vitamin D may increase susceptibility to internal cancer as well as infection, hypertension and autoimmune disorders. Since the sun stimulates production of vitamin D precursors in the skin while sunscreens reduce production it is speculated some of us could be vitamin D deficient and thus at risk for these disorders. Are you now thinking of tossing out your sunscreens and going to the beach or purchasing a package of tanning parlor visits? Hold on! This confusion is a classic example of a “little knowledge is a dangerous thing”.

We have known for many years that sunscreens prevent sunburn and skin cancer by blocking the UVB rays that vary in intensity throughout the year. We now know that longer, more deeply penetrating UVA rays which account for more the 90% of UV light and stay relatively constant throughout the year also play a role in skin cancer as well as skin wrinkling. This is why dermatologists now recommend the newer generation of “broad spectrum” sunscreens that block both groups of rays. SPF rates the amount of UVB protection and the FDA will soon be releasing a new 4-star UVA rating system to quantity the amount of UVA protection. For day to day use (unless you work out of doors or plan recreational sun exposure) a SPF 15 is more than sufficient for most of us. Unfortunately, some commit “sunscreen abuse”, meaning they now go out much longer than before with the false expectation they are getting no sun damage. They may rationalize that by increasing to a SPF 30 they have doubled their protection. Not so fast! A SPF 15 sunscreen blocks 93% of UVB rays, while a SPF 30 blocks 97%–not much additional protection for the increased cost and irritancy!

A few years ago, some studies disclosed a relationship between internal cancer (esp. colorectal cancer) and vitamin D deficiency. In other words, vitamin D perhaps served a “protective” role and since suncreens and/or strict sun avoidance reduced vitamin D production it was speculated by some and politicized by others as a rational to abandon photoprotection altogether. Making matters worse, some suggested that the vast majority of Americans were vitamin D deficient, while others stated the daily recommendation for vitamin D was too low. Some are now promoting increased sunbathing and utilization of tanning salons, despite the mounting evidence that UVA (the light rays emitted by tanning salons) causes skin cancer, in particular, melanoma and premature aging.

Many subsequent studies assessing the role of vitamin D in “protecting” against internal cancer have conflicting results and it will take many years with long-term prospective studies to know for sure. As well, there is controversy regarding the extent, if any, of significant vitamin D deficiency in Americans. Nonetheless, you can obtain vitamin D from diet (e.g. salmon, fortified milk and orange juice) without subjecting yourself to the risk of sun exposure. The National Institutes of Health claims it doesn’t take much sunlight to make adequate vitamin D-likely as little as 30 minutes twice a week without sunscreen!. Alternatively, simply taking supplemental vitamin D (1,000 IU) if you have had skin cancer, are at risk for skin cancer, or simply want to avoid the unsightly wrinkling and discoloration caused by habitual sun exposure is a much safer way to assure adequate levels. My closing recommendation is moderation and see your dermatologist annually!

Article by: Neil Alan Fenske, MD. Professor and Chairman of the Department of Dermatology and Cutaneous Surgery at the University of South Florida

http://health.usf.edu/medicine/dermatology/bios/bio_fenske.htm

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‘USF Health Dermatology and Cutaneous Surgery’

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The Woman Whose Legs Turned Black

Mystery Diagnosis Video

When Diane’s legs turn black, doctors think they’ll have to amputate! Premiering Monday, March 8. Diane’s amazing story will take you on a roller coaster ride of emotions as she endures misdiagnoses and dismissals before finding an answer!

FOR IMMEDIATE RELEASE

PR Log (Press Release) – Feb 24, 2010 – Discovery Health’s popular show MYSTERY DIAGNOSIS will spotlight Eagle, Colorado resident Dr. Diane Dike this March. As part of the hit series’ eighth season, will share her riveting story with audiences across the nation. Diane’s show, premiering on Monday, March 8, at 10 PM ET/PT, will take you on a roller coaster ride of emotions as she endures misdiagnoses and dismissals before ever finding an answer!

In the fall of 1990, Diane felt that her life had never been better—she was married to her high school sweetheart and working in her dream job as a teacher and professor.  One day, Diane, noticed two red bumps on her right foot, coupled with a strange sensation.  After initially dismissing the bumps as a spider bite, Diane awakened the next morning to excruciating pain with her foot completely red and swollen twice its normal size. Diane crawls for help and rushes to the emergency room, where she is told that her puzzling symptoms are the result of a simple bruise from unknowingly hitting her foot.  The doctor directs her to stay off of her foot , ice and to take anti-inflammatory pills, which helps at first—but a few days later, Diane finds her legs covered in red spots. As visits to her family doctor and multiple specialists yield no answers,, Diane’s symptoms persist–and then, six months after her initial symptoms began, her legs turn completely black. Terrified, Diane goes back to the emergency room—but after five days in the hospital, the symptoms fade and, still with no answers, she is discharged. Diane continues to suffer and, her flare ups only get worse and more frequent.  In a last ditch attempt to find a diagnosis, Diane’s doctor sends her to the University of South Florida to seek help, where she is finally diagnosed with Cryoglobulinemia, a blood disorder which causes the blood to turn into a jelly-like substance when her temperature drops below 98.6 degrees. Because there is presently no cure for this disease, Diane must regularly take medicine, keep her extremities warm and avoid stress on her body. Diane didn’t handle the illness and lost everything. After a difficult divorce, becoming homeless, suicidal and ending up in a psych. ward. Today, Diane’s an award winning Author, Speaker, Singer, Counselor, Rare Blood Disease Survivor. She’s  remarried and created an outreach organization called Second Chance with Saving Grace. After rescuing an abandoned, broken Italian Greyhound Diane trained her to be her service dog and now they go where no woman and dog have gone before. She’s learned to live with her disease while finding ways to help others.

Discovery Health’s award-winning MYSTERY DIAGNOSIS chronicles the experiences of patients who suffer from conditions outside of the medical mainstream and goes into over 73 million homes.  Each episode features patients who are initially misdiagnosed or undiagnosed altogether due to the uncommon nature of their symptoms and general lack of awareness regarding their conditions. This popular series—now in its eighth season on Discovery Health—profiles the strength and courage of heroic patients like Dr. Diane Dike and determined medical practitioners as they struggle to make sense of baffling conditions.

*Review DVD screeners and interviews available upon request. Check your local listing for air time. “The Woman Whose Legs Turned Black.”  When Diane’s legs turn black, doctors think they’ll have to amputate watch, Monday, March 8, 2010.

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Contact Allergy Link

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Winter itch is the curse of the changing season

TBO.com Photo

I’m sure many of you have noticed that your skin has become itchy since the recent cold wave hit our area. Our “snowbird” friends from up North are quite familiar with this phenomenon they call “winter itch.”

Are they bringing with them some exotic disease, or is it related to the cold weather that drives (and often follows) them here?

“Winter itch” is a common skin problem that is triggered by cold weather. The problem is much greater in colder climates where they use more heat and the humidity is lower. Nonetheless, it also occurs in the South, especially when these more severe cold waves pass through.

Recently, I observed in many of my patients the telltale signs of winter itch characterized by dry skin, most notable on the lower legs and the arms, dry and cracked nail cuticles, chapped lips and many scratch marks. When queried, they all complained of itchy skin.

The cause of winter itch is well known. It is due to rapid and excessive dryness of the skin that occurs as winter descends upon us. During winter the humidity is lower; when the heat is on, the warm circulating air tends to dry the skin further. Simply remember how dry your skin got the last time you traveled North in the winter!

Moreover, when it’s cold outside many of you love to take a long, hot shower or bath — but this can actually aggravate your condition. What happens is that your waterlogged skin dries out due to the effects of evaporation, which is accelerated as the humidity decreases and the household heat increases. Since evaporation is a drying process, it is imperative to prevent it by applying a moisturizer within five minutes of towel drying. That will lock in the residual moisture.

Over time this will rehydrate your skin as well. If winter itch gets out of hand, your skin can become inflamed, resulting in “xerotic” eczema. The process is much worse if you have preexisting dry skin due to aging or atopic eczema (a common skin disorder characterized by sensitive skin associated with asthma and hay fever).

Here are some tips to prevent and/or treat “winter itch:”

• Turn down the thermostat.

• Avoid hot showers & baths (they degrease the skin).

• Limit bathing to five to10 minutes (less water, less evaporation).

• Use super-fatted soaps (fewer suds) or, better yet, soap-free cleansers.

• Pat dry and immediately apply a moisturizer while skin is still wet!

• Moisten and reapply moisturizer as necessary.

• Avoid irritating clothing (wool).

• If the skin is inflamed, apply 1 percent hydrocortisone cream, available over the counter.

• If the condition doesn’t resolve, see your dermatologist!

What do I look for in a moisturizer?

• It doesn’t have to be expensive to be good! (Same ingredients, different packaging.)

• Heavier is better (Less water-less drying via evaporation)

• Fragrance free better (Avoids allergens)

• Basic moisturizers are petrolatum based with emulsifiers. (They trap water in the skin by occlusion. Cost effective!)

• Enhanced moisturizers contain alpha hydroxyl acids, urea and hyaluronic acids. (They hold water in the skin and help normalize the damaged epidermis.)

• Pure petrolatum lip balms are best. (The more ingredients, the greater the risk for allergies.)

Dr. Fenske is professor and chair of the Department of Dermatology and Cutaneous Surgery at USF Health.

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Hypnosis – Applications in Dermatology and Dermatologic Surgery

Author: Philip D Shenefelt, MD, MS, Associate Professor, Department of Dermatology and Cutaneous Surgery, University of South Florida College of Medicine; Past Chief, Section of Dermatology, James A Haley Veteran Affairs Medical Center
Contributor Information and Disclosures

Updated: Apr 23, 2009

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Introduction

Hypnosis is the intentional induction, deepening, maintenance, and termination of the natural trance state for a specific purpose. For the much maligned stage hypnosis, the purpose is entertainment. For medical hypnotherapy, the purpose is to reduce suffering, to promote healing, or to help the person alter a destructive behavior. The hypnotic phenomenon has been used since antiquity to assist in healing.

All individuals enter spontaneous mild trances daily while absorbed in watching television or a movie, in reading a book or a magazine, or in another activity or meditation. With appropriate training, an individual may intensify this trance state in himself or herself or in another individual and use this heightened focus to induce mind-body interactions that help to alleviate suffering or to promote healing. The trance state may be induced by using guided imagery, relaxation, deep breathing, meditation techniques, self-hypnosis, or hypnosis induction techniques. Individuals vary in their ability to enter the trance state, but most can obtain some benefit from hypnosis.

In dermatology, hypnosis may help decrease pain and pruritus in the skin; intervene in psychosomatic aspects of skin diseases; and lead to the resolution of some skin diseases, including verruca vulgaris. Suggestion without formal trance induction may be effective in some cases. Sulzberger and Wolf1 reported on the use of suggestion to treat verrucae.

Precisely defining hypnosis has proven to be challenging. Marmer2described hypnosis as a psychophysiological tetrad of altered consciousness consisting of narrowed awareness, restricted and focused attentiveness, selective wakefulness, and heightened suggestibility. For a more detailed discussion of the definitions of hypnosis, see the texts by Crasilneck and Hall3 or Barabasz and Watkins.4 Many myths exist about hypnosis that overrate, underrate, or distort the true capabilities of hypnosis.

Hypnosis can regulate blood flow and other autonomic functions that are not usually under conscious control. The relaxation response that occurs with hypnosis also affects the neurohormonal systems that regulate many body functions. Studies on the influence of hypnosis on immediate immune responses have shown the ability of hypnotized volunteers to significantly decrease the flare reaction to the histamine prick test. Similarly, in one study, the effect of hypnotic suggestion on delayed cellular immune responses has shown significant effect on the size of erythema and on palpable induration but no significant effect in other studies.

A report by Braun5 on different allergic responses; dermatologic reactions; and effects on seizure disorders, pain control, and healing in the same individual with multiple personality disorder (now called dissociative identity disorder) shows how much influence the mind can have on physiologic reactions and disease processes, depending on the personality present. The report also described the differences in physiologic responses and disease conditions for selected individuals under hypnosis compared with their normal waking state.

Hypnosis may be used to increase healthy behaviors, to decrease situational stress, to reduce needle phobias, to control harmful habits (eg, scratching), to provide immediate and long-term analgesia, to ameliorate symptoms related to diseases (eg, pruritus), to accelerate recovery from surgery, and to enhance the mind-body connection to promote healing. Hypnosis can be especially helpful in dealing with skin diseases that have a psychosomatic aspect. Griesemer,6 who was trained both in dermatology and in psychiatry, recorded the incidence of emotional triggering of dermatoses in his patients during 1 year in his practice. He developed an index for various skin diseases, with 100 indicating an absolute psychosomatic component and zero indicating no psychosomatic component to the skin disease.

Good references on the responsiveness of skin diseases to hypnosis are found in the somewhat outdated book by Scott7 and in the chapter on the use of hypnosis in dermatologic problems in the text by Crasilneck and Hall.3Koblenzer8 also mentions some of the uses of hypnosis in common dermatologic problems. In an excellent resource book for patients, Grossbart and Sherman9 discuss mind-body interactions in skin diseases and include hypnosis as recommended therapy for a number of skin conditions.

Methods of Medical Hypnotherapy

Hypnosis is not a therapy in and of itself. Instead, it is a tool that can be used to reveal psychological and behavioral roadblocks to healing. Therapies that can be enhanced by hypnosis include supportive (ego-strengthening) therapy, direct suggestion, symptom substitution, and hypnoanalysis.

In adults, induction of the hypnotic state is achieved by any of a number of methods that focus attention, soothe, and/or produce monotony or confusion. In children, the hypnotic state can be induced by having the child make-believe that he or she is watching television, a movie, or a play or by using some other distractive process that uses the imagination.

Supportive (ego-strengthening) therapy while in a hypnotic state includes positive suggestions of self-worth and effectiveness. Posthypnotic suggestion is often included, and further strengthening of the effect can be obtained by recording an audiocassette tape that the patient can repeatedly use for self-hypnosis later. The strengthened ego is better able to repress or confront discordant elements that inhibit healing.

Direct suggestion while in the hypnotic state is a frequently used method of decreasing discomfort from pain, pruritus, burning sensations, anxiety, and insomnia. Again, posthypnotic suggestion and repeated use of an audiocassette tape for self-hypnosis help to reinforce the effectiveness of direct suggestion. Direct suggestion may produce a sufficiently deep anesthesia in highly hypnotizable individuals for cutaneous surgery. Direct suggestion can also be used to reduce repetitive acts of skin scratching or picking, nail biting or manipulating, and hair pulling or twisting. Unwanted psychophysiologic responses, such as hyperhidrosis, blushing, and some types of urticaria, can also be controlled by direct suggestion. Some skin lesions can even be induced to resolve by using direct suggestion; the classic example is verrucae.

Symptom substitution retrains the subconscious by means of hypnosis to replace a negative habit pattern with a more constructive one. For example, scratching can be replaced by another physical activity, such as grabbing onto something and holding it so tightly for a half minute that it almost hurts. Other stress relievers that can be substituted for scratching include athletic activities, artwork, verbal expression of feelings, or meditation.

Hypnoanalysis may help patients with chronic psychosomatic dermatoses that are nonresponsive to other simpler approaches. LeCron’s10,11 list of the 7 most common factors causing emotional difficulties and illnesses (ie, conflicts, motivation, the effect of suggestion, organ language, identification, self-punishment, and the effect of past experiences) is a good starting point for exploration in hypnoanalysis. Ewin and Eimer12 provide a user-friendly method of detecting and neutralizing the emotional impact of sensitizing or precipitating events. They use ideomotor signaling to obtain recollection of significant memories that may be preverbal or nonverbal. Results may occur more rapidly than with standard psychoanalysis. Only well-qualified and appropriately licensed practitioners should perform these types of hypnosis.

The author discusses the successful use of hypnoanalysis in dermatology.13The author has slightly modified Ewin’s mnemonic for LeCron’s 7 key factors to COMPASS, as follows:

§  C onflict

§  O rgan language

§  M otivation

§  P ast experiences

§  A ctive identification

§  S elf-punishment

§  S uggestion

The diagnostic value of screening for psychosomatic factors related to skin disorder triggering or exacerbation is illustrated in the above case. It is possible to rule out a likely psychosomatic component if the focused history and COMPASS ideomotor questioning for all 7 factors is negative. With 1 or 2 factors positive, appropriate reframing may be sufficient, but with more factors positive, more intensive psychotherapy would be appropriate.

Hypnotic Relaxation During Dermatologic Surgery

A variety of dermatologic procedures can produce pain or anxiety in patients. Skin procedures that are somewhat painful but usually do not require a local anesthetic include moderate depth chemical peels, cryodestruction of skin lesions, curettage of molluscum, excision of skin tags, extrusion of comedones, incision and expression of milia, laser treatment of vascular lesions, strong microdermabrasion, and sclerotherapy. Dermatologic procedures that require a local anesthetic include electrodesiccation and curettage, incision and drainage of an abscess, laser ablation of skin lesions, liposuction, punch biopsy, shave biopsy, surgical excision, and surgical repair. Cutaneous procedures that may require conscious sedation include deep chemical peels, dermabrasion, laser resurfacing, and extensive liposuction. All of these procedures may be augmented by hypnotic relaxation and/or hypnotic analgesia.

Recent experimental evidence helps to elucidate the nature of the mechanisms of pain relief during hypnosis. Faymonville et al found that pain reduction mediated by hypnosis was localized to the mid anterior cingulate cortex, as observed by using a positron emission tomography (PET).14

In an electroencephalographic (EEG) study of hypnosis effects versus distraction effects on cold pressor pain, Freeman et al15 observed significantly greater high theta (5.5-7.5 Hz) activity in persons who were highly susceptible to hypnosis (based on the Stanford Hypnotic Susceptibility Scale, Form C or SHSS:C scores) compared with persons who were less susceptible to hypnosis at parietal and occipital sites during both hypnosis and waking relaxation. Freeman et al also found that in persons who were highly susceptible to hypnosis, hypnosis provided significantly greater pain relief than distraction or waking relaxation. These individuals also had significantly greater pain relief via hypnosis than those who were less susceptible to hypnosis. These PET and EEG studies support state-based theories of hypnosis as opposed to sociocognitive theories of hypnosis.

Until recently, the clinical literature on hypnosis for pain and anxiety relief was mostly on the case report level. In older literature, Blankfield16reviewed adjunctive hypnosis in the care of patients who underwent surgery. Overgeneralizing from case reports can be risky.

In a meta-analysis of hypnotically induced analgesia, Montgomery et al17found that hypnosis relieved pain in patients with headache, burn injury, heart disease, cancer, dental problems, eczema, and chronic back problems. Their study quantified the magnitude of hypnoanalgesic effects. For most people, hypnotic suggestion relieved pain regardless of its type.

Light and medium trance states are sufficient for most purposes, but a deep trance state is required for hypnotic anesthesia for surgery. Faymonville et al18 randomly assigned 60 patients undergoing plastic surgery with conscious sedation either to a control group with stress-reducing strategies or to a hypnosis group. Intraoperative and postoperative anxiety and pain were significantly lower and significantly smaller amounts of medication were required for conscious sedation in the hypnosis group.

Mauer et al19 studied 60 patients who underwent hand surgery and received either standard treatment or standard treatment augmented with hypnosis. The hypnosis group had significantly decreased perceived pain intensity, expression of perceived pain, and anxiety compared with those of control subjects. Patients in the hypnosis group also had significantly fewer medical complications and a higher postoperative recovery rate.

Montgomery et al20 studied 20 women randomized to standard care versus preoperative hypnosis for excisional breast biopsy. They found brief (10 min) hypnosis to be effective in reducing postsurgery pain and distress both before surgery and after surgery. Defechereux et al21 reported a prospective randomized study of thyroid and parathyroid procedures performed under hypnosis, local anesthesia, and minimal conscious sedation in patients compared with similar surgery performed under conventional anesthesia in 20 patients. Defechereux et al found that patients in the hypnoanesthesia group had significantly less inflammatory response, hemodynamic dysregulation, postoperative pain, postoperative fatigue, and convalescence time. Bleeding, operative times, and surgical comfort were similar in both groups.

Lang et al22 conducted a prospective randomized trial of adjunctive nonpharmacologic analgesia for invasive radiologic procedures in 3 groups: percutaneous vascular radiologic intraoperative standard intravenous conscious sedation care; structured attention; and intravenous conscious sedation that included self-hypnotic relaxation. Pain increased linearly with time in the standard group and in the structured attention group, but it remained flat in the hypnosis group. Anxiety decreased over time in all 3 groups but more so in the hypnosis group. Drug use was significantly higher in the standard group, intermediate in the structured attention group, and lowest in the self-hypnosis group. Hemodynamic stability was significantly higher in the hypnosis group than in the other 2 groups. Procedure times were significantly shorter in the hypnosis group than in the standard group. Individual imagery was quite varied.23

Lang et al22 concluded that hypnosis worked better in reducing pain and anxiety, in maintaining hemodynamic stability, and in shortening the procedure time than standard intraprocedural care; the results of the structured attention group were in between those of the hypnosis group and the standard care group.

Lang and Rosen24 used the data from the above study to perform a cost analysis of standard intravenous conscious sedation compared with intravenous conscious sedation that included self-hypnotic relaxation. The average cost per case associated with standard sedation was $638 compared with an average cost of $300 per case for sedation augmented by hypnosis. The cost savings averaged $338 per case.

Permitting the patient to choose his or her own self-guided imagery seems to allow most individuals to reach a state of relaxation during procedures. The author has used the technique from the invasive radiologic studies modified for dermatology with good success in dermatologic surgery.25 Eye-roll induction was most commonly used by the author; this method works quickly for most patients.

Hypnotherapy for Specific Dermatologic Conditions

Much of the older literature about the effectiveness of hypnosis on specific dermatologic conditions is based on one or a few uncontrolled cases. The word may is used below to qualify recommendations that are based on weak evidence. In recent years, randomized controlled trials have produced more reliable information. Unfortunately, randomized controlled trial results are still not available for most of the disease categories. The list of dermatologic conditions below is not all-inclusive, but it does include most of the dermatologic conditions for which hypnosis is reasonably helpful in reducing symptoms or in improving aspects of the condition. They are arranged on the basis of the strength of scientific evidence for the effectiveness of hypnosis, starting with the strongest evidence.26 Those dermatologic conditions supported by only one or a few case reports are listed in alphabetical order toward the end of this section, starting with acne excoriée.

Randomized controlled trials

Verruca vulgaris27

The early report by Sulzberger1 on the efficacy of suggestion in treating warts has since been confirmed numerous times. Numerous reports attest to the efficacy of hypnosis in treating warts.28,29 In a well-conducted randomized controlled study by Spanos et al30 that serves as a typical example, 53% of the experimental group had improvement of their warts 3 months after the first of 5 hypnotherapy sessions, while none of the control group had improvement. Hypnosis can be successful as a therapy for warts.

Psoriasis

Stress is often a factor in the onset, exacerbation, and prolongation of psoriasis. Hypnosis and suggestion have been shown to have a positive effect on psoriasis. In a typical case report, 75% clearing of psoriasis was reported by using a hypnotic sensory-imagery technique. A case of extensive, severe psoriasis of 20 years’ duration showed marked improvement by using sensory imagery to replicate the sensations in the patient’s skin that he had experienced during sunbathing. Another case of severe psoriasis of 20 years’ duration fully resolved with a hypnoanalytic technique.

Tausk and Whitmore31 performed a small randomized double-blind controlled trial by using hypnosis as adjunctive therapy in psoriasis, with significant improvement in individuals who were highly susceptible to hypnosis. Hypnosis can be useful as an adjunct therapy for resistant psoriasis, especially if an emotional factor is significant in the triggering of the psoriasis.

Venipuncture in children

Liossi et al conducted a prospective, randomized, controlled trial to compare the efficacy of a local anesthetic (EMLA), EMLA plus hypnosis, or EMLA plus attention in children receiving venipuncture. Children in the EMLA-plus-hypnosis group reported less anticipatory anxiety and less procedure-related pain and anxiety; they were rated as demonstrating less behavioral distress during the procedure than patients in the other 2 groups. Additionally, parents whose children were randomized to the EMLA-plus-hypnosis group experienced less anxiety during their child’s procedure than parents whose children had been randomized to the other 2 groups.32

Nonrandomized controlled trials

Atopic dermatitis

Stewart and Thomas33 treated 18 adults with extensive atopic dermatitis whose conditions had been resistant to conventional treatment with hypnotherapy. In a nonrandomized controlled study, they used relaxation, stress management, direct suggestion for nonscratching behavior and for skin comfort and coolness, ego strengthening, posthypnotic suggestions, and instruction in self-hypnosis. The results were statistically significant for reduction in itching, scratching, sleep disturbance, and tension. The use of topical corticosteroids decreased from the original amount by 40% at 4 weeks, 50% at 8 weeks, and 60% at 16 weeks. For milder cases of atopic dermatitis, hypnosis, along with moisturizing, can be sufficient as a primary treatment. For more extensive or resistant atopic dermatitis, hypnosis can reduce the required amount of other conventional treatments.34

Case series

Alopecia areata

Gupta et al35 found a strong correlation between high stress reactivity and depression in patients with alopecia areata. Willemson et al36 used hypnotherapy for 21 patients, 9 with alopecia universalis and 12 with extensive alopecia areata. After hypnotherapy, all patients had significantly lower anxiety and depression. Complete scalp hair regrowth occurred in 9 patients, including 4 with alopecia universalis and 2 with ophiasis. Over 75% scalp hair regrowth occurred in another 3 patients. Five patients had a significant relapse of alopecia. Hypnosis is appropriate as a stress reducer and sometimes is successful as a primary treatment method for alopecia areata.

Urticaria

Two cases of urticaria responding to hypnotic suggestion were reported in a study. The study included an 11-year-old boy whose urticarial reaction to chocolate could be blocked by hypnotic suggestion so that hives appeared on only one side of his face in response to that hypnotic suggestion. A case series study of hypnosis with relaxation therapy on 15 patients with chronic urticaria for an average duration of 7.8 years showed that within 14 months, 6 patients’ conditions had cleared and 8 had improved, with decreased medication requirements reported by 80% of patients. One patient’s condition did not improve. Hypnosis may be useful as a therapy for chronic urticaria.

Individual case reports

Acne excoriée

Hollander37 reported success in controlling the picking aspects of acne excoriée in 2 cases by using posthypnotic suggestion. While in a hypnotic state, the patient was instructed to remember the word scar whenever she wanted to pick her face and to refrain from picking by saying scar. The excoriations resolved but not the underlying acne. The author has also used this technique successfully.38 Hypnosis, combined with standard acne treatments for the acneiform aspects, may be an appropriate treatment of the excoriation aspect of acne excoriée.

Congenital ichthyosiform erythroderma

Several cases of remarkable clearing of congenital ichthyosiform erythroderma of Brocq have been reported following direct suggestion for clearing under hypnosis. For example, Kidd39 reported improvement in a 34-year-old father and his 4-year-old son. Hypnosis, in addition to the use of emollients, may potentially be useful.

Dyshidrotic dermatitis

Reduction in the severity of dyshidrotic dermatitis has been reported with the use of hypnosis as a treatment. Greisemer’s6 data indicate a significant psychosomatic component for dyshidrosis; therefore, hypnosis may be useful as a therapy.

Erythema nodosum

Resolution of erythema nodosum of 9-year duration occurred in a 44-year-old woman after hypnoanalysis.13 Five of the 7 key COMPASS factors were positive in this case.

Erythromelalgia

One case report exists of successful treatment of erythromelalgia in an 18-year-old woman using hypnosis alone followed by self-hypnosis. Permanent resolution occurred.

Furuncles

Jabush40 described a 33-year-old man with recurrent (since age 17 y), multiple furuncles that containedStaphylococcus aureus; the furuncles were unresponsive to multiple treatment modalities. The patient had a negative self-image. Hypnosis and self-hypnosis with imagined sensations of warmth, cold, tingling, and heaviness resulted in dramatic improvement over 5 weeks, with full resolution of the recurrent furuncles. He also substantially improved from a mental standpoint. The hypnosis was hypothesized to have helped in some way to normalize the immune response to the bacteria. Conventional antibiotic therapy is the first line of treatment for furuncles; however, in unusually resistant cases with significant psychosomatic overlay, hypnosis may help to end the recurrent cycles of infection.

Glossodynia

When oral pain has a psychogenic component, hypnosis may be effective as a primary treatment. Even with organic disease, hypnosis may temporarily relieve pain.41

Herpes simplex

Lessening of discomfort from herpes simplex eruptions is similar to that for postherpetic neuralgia. Reduction in the frequency of recurrences of herpes simplex following hypnosis has also been reported. In cases with an apparent emotional trigger factor, hypnotic suggestion may be useful as a therapy for reducing the frequency of recurrence.

Hyperhidrosis

Hypnosis and autogenic training may be useful as adjunctive therapies for hyperhidrosis.

Ichthyosis vulgaris

A 33-year-old man with chronic ichthyosis vulgaris that was better in the summer and worse in the winter began hypnotic suggestion therapy in the summer and was able to maintain the summer improvement throughout the fall, winter, and spring. Hypnosis may be useful as an adjunct therapy for ichthyosis.

Lichen planus

Both the pruritus and the lesions may be reduced in selected cases by using hypnosis as a therapy for lichen planus.

Neurodermatitis

Several cases of neurodermatitis have reportedly resolved by using hypnosis as a therapy. Neurodermatitis remained resolved, with up to 4 years of follow-up.42 Iglesias43 reported 3 cases of neurodermatitis that failed to respond to direct suggestion under hypnosis but that responded to hypnoanalysis with ideomotor signaling followed by reframing. Hypnosis may be useful as a therapy for neurodermatitis.

Nummular dermatitis

Reduction of pruritus and resolution of lesions have been reported with the use of hypnotic suggestion as complementary therapy for nummular dermatitis.

Postherpetic neuralgia

The pain of acute herpes zoster and postherpetic neuralgia can be reduced by hypnosis. Hypnosis may have a place as a therapy for postherpetic neuralgia.

Pruritus

The intensity of pruritus may be modified and improved by hypnosis. For example, a man with chronic myelogenous leukemia had intractable pruritus, which improved with hypnotic suggestion. Hypnosis may be used as a therapy for intractable pruritus.

Rosacea

Improvement of rosacea, especially the vascular blush component, has been reported in selected cases of resistant rosacea where hypnosis has been added as a therapy.

Trichotillomania

Several cases of successful adjunctive treatment of trichotillomania with hypnosis have been reported. Hypnosis may be a useful therapy for trichotillomania.44

Vitiligo

Hautmann and Panconesi45 detailed the psychoneuroendocrinimmunologic aspects and mechanisms of vitiligo. Occasional cases of vitiligo have improved by using hypnotic suggestion as a therapy.

Advantages and Disadvantages of Hypnotherapy

Hypnosis is currently an underused therapy in dermatology. In appropriately selected patients, it can decrease or eliminate symptoms, and, in some cases, it can induce lasting remissions or cures of skin diseases. Discussing this option with patients allows the dermatologist to gauge the patient’s receptiveness to this treatment modality. The time requirements for screening patients, educating them about realistic expectations for results from hypnosis, and performing the hypnotherapy are generally no longer than those for screening, preparing, and educating patients about cutaneous surgery and then performing it.

Many dermatologists choose to refer patients with complex cutaneous surgical problems to competent specialists in dermatologic surgery. Likewise, many dermatologists choose to refer patients with complex psychosomatic dermatologic problems to competent specialists in hypnosis-assisted therapy. Those dermatologists who prefer to refer patients to hypnotherapists may obtain referrals and information from the American Society of Clinical Hypnosis or similar professional organizations.

Advantages of medical hypnotherapy for skin diseases include the ability to obtain a response where other treatment modalities have failed; the ability to reduce relapses; and the ability of patients to self-treat and gain a sense of control when taught self-hypnosis reinforced by using audiotapes, nontoxicity, and cost-effectiveness. Adding this treatment can result in pleased and grateful patients.

Disadvantages of medical hypnotherapy in dermatology include the extensive training required; the low hypnotizability of some patients; the negative social attitudes still prevalent about hypnosis; and the lower reimbursement rates for cognitive therapies, such as hypnosis, when compared with procedural therapies, such as cutaneous surgery. The low hypnotizability of some individuals is consistent over time, as measured by the Hypnotic Induction Profile.

Training in Medical Hypnotherapy

The American Society of Clinical Hypnosis offers weekend, regionally held, 20-hour courses in beginning, intermediate, and advanced hypnosis. Information may be obtained from its Web site (ie, American Society of Clinical Hypnosis). Other organizations also offer training. Mentors are available once the practitioner has obtained the necessary basic training.

Legal Requirements for Practicing Medical Hypnotherapy

In the United States, a state license is required to practice medicine. The exact details in terms of legal limitations vary from state to state; therefore, checking state statutes is recommended and imperative. In some states (eg, Florida), the practice of hypnotherapy is limited to licensed practitioners. The training requirements depend on the type of license. Outside of the United States, most jurisdictions have their own laws or statutes that dictate who may legally practice hypnosis. One should check for details in his or her local area.

As with all medical procedures, informed consent is crucial before proceeding with medical hypnotherapy. Although it does not need to be a written consent, informed consent should be well documented in the patient’s chart if no written form is signed by the patient.

In many states, prior hypnosis may be considered to taint the memory with respect to legal testimony given by patients if they are plaintiffs, victims, or witnesses. If the area to be addressed by medical hypnotherapy might be open to future litigation, the credibility of the patient’s testimony may suffer. This potential legal issue should be included in the informed consent discussion.

Delving into repressed memories is a legally risky issue because of legal claims by patients that therapists have created false memories. Only adequately trained physicians, psychiatrists, and psychologists who know how to avoid asking leading questions should venture into this area.

The above information is not warranted to be legally correct. If indicated by the situation, conferring with a qualified attorney to obtain legal advice is recommended.

Patient Selection

Suitable candidates for the use of hypnosis are patients who are mentally intact; not psychotic or intoxicated; motivated, not resistant; and preferably moderately or highly hypnotizable, as rated by the Hypnotic Induction Profile described by Spiegel and Spiegel or by the Stanford Hypnotic Susceptibility Scale and its variants. However, a moderate or high degree of hypnotizability is not critical to the success of self-guided imagery for relaxation and discomfort reduction.

Patient selection is an important aspect of successful medical hypnotherapy in dermatology. Hypnosis-assisted therapy works best in moderately to highly hypnotizable patients who are appropriately motivated and who have dermatoses with a large psychosomatic component or are otherwise known to be responsive to intervention with hypnosis. As with any therapy, starting with simple, easy cases is best, referring the more complex cases to those with more experience. As the practitioner gains experience, more difficult cases may be added.

When appropriately applied, hypnosis can be effective and gratifying in many cases. It is not a panacea. Although it appears to work miracles for some and to fail completely for others, most results lie somewhere in between. A key factor in producing positive results is the specific type of therapy chosen to be assisted by hypnosis. Careful selection of the disease process, the patient, and the provider, as well as appropriate use of hypnosis, can decrease suffering and morbidity from skin disorders with minimal adverse effects.

For moren information on Dr. Philip Shenefelt visit: http://health.usf.edu/medicine/dermatology/bios/bio_shenefelt.htm

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