Journal Article Annotations
2024, 2nd Quarter

Psychodermatology

Annotations by J. Jewel Shim, MD, FACLP, FAPA
July, 2024

Dermatological patients with itch report more stress, stigmatization experience, anxiety and depression compared to patients without itch: Results from a European multi-centre study.
Brain mechanisms for processing caress-like touch in skin-picking disorder.

- Mind and skin: Exploring the links between inflammation, sleep disturbance and neurocognitive function in patients with atopic dermatitis.

PUBLICATION #1 — Psychodermatology

Dermatological patients with itch report more stress, stigmatization experience, anxiety and depression compared to patients without itch: Results from a European multi-centre study.

C Zeidler, J Kupfer, F J Dalgard, A Bewley, A W M Evers, U Gieler, L Lien, F Sampogna, , L Tomas Aragones, N Vulink, A Y Finlay, F J Legat, G Titeca, G B Jemec, L Misery, C Szabó, V Grivcheva Panovska, S Spillekom van Koulil, F Balieva, J C Szepietowski, A Reich, B R Ferreira, A Lvov, D Romanov, S E Marron, T Gracia Cazaña, A Elyas, I K Altunay, A R Thompson, S van Beugen, Ständer, C Schut.

Abstract: Comparative Study. 2024 Aug;38(8):1649-1661. doi: 10.1111/jdv.19913. Epub 2024 Mar 12.

Background:
Itch as the most common symptom in dermatology has been shown to be related to psychological factors such as stress, anxiety and depression. Moreover, associations were found between perceived stigmatization and itch. However, studies investigating the differences between patients with dermatoses with and without itch regarding perceived stress, stigmatization, anxiety and depression are missing. Therefore, one of the aims of the second study of the European Society for Dermatology and Psychiatry (ESDaP study II) was to investigate these relationships in a large cohort of patients with different itchy dermatoses.

Results:
3399 patients with 14 different itchy dermatoses were recruited at 22 centres in 17 European countries. They filled in questionnaires to assess perceived stigmatization, stress, signs of clinically relevant anxiety or depression, itch-related quality of life, the overall health status, itch duration, frequency and intensity. The most significant association between the severity of itching and the perception of stress was observed among individuals with rosacea (correlation coefficient r = 0.314). Similarly, the strongest links between itch intensity and experiences of stigmatization, anxiety, and depression were found in patients with seborrheic dermatitis (correlation coefficients r = 0.317, r = 0.356, and r = 0.400, respectively). Utilizing a stepwise linear regression analysis, it was determined that within the entire patient cohort, 9.3% of the variation in itch intensity could be accounted for by factors including gender, levels of anxiety, depression, and perceived stigmatization. Females and individuals with elevated anxiety, depression, and perceived stigmatization scores reported more pronounced itch intensities compared to those with contrary attributes.

Conclusion:
This study underscores the connection between experiencing itch and its intensity and the psychological strain it places on individuals. Consequently, psychological interventions should encompass both addressing the itch itself and the interconnected psychological factors. In specific cases, it becomes imperative for dermatologists to direct individuals towards suitable healthcare resources to undergo further psychological assessment.

Annotation

The finding:
The study authors hypothesized that patients with more severe itchy dermatoses were more likely to have higher stress, perceived stigma, and increasedanxiety and depression. The strongest correlation between itch intensity and perceived stress was in subjects with rosacea, while patients with seborrheic dermatitis had the highest correlation between itch intensity, stigmatization, and anxiety or depression. All patients with greater itch intensity had lower overall health status.

Strength and weaknesses:
A major strength was the study’s large size and with multiple study centers. However, its inclusion of 14 different pruritic dermatoses, may dilute the ability to draw clear conclusions regarding individual skin conditions. This study furthered previous data citing a correlation between certain dermatoses, sleep disruption, and mental health disorders. However, the cross-sectional study design could only describe an association between the variables.

Relevance:
This study highlights the importance of itch as impactful symptom focus in the evaluation and treatment of patients with skin disorders and comorbid psychiatric disorders.

PUBLICATION #2 — Psychodermatology

Brain mechanisms for processing caress-like touch in skin-picking disorder.

Anne Schienle, Carina Schlintl, Albert Wabnegger.

Abstract: Eur Arch Psychiatry Clin Neurosci. 2024 Feb;274(1):235-243. doi: 10.1007/s00406-023-01669-9. Epub 2023 Aug 23.

Skin-picking disorder (SPD) is characterized by repetitive touching and picking of one’s skin. The picking is typically experienced as pleasant although this behavior leads to tissue damage. The present functional magnetic resonance imaging (fMRI) study investigated how individuals with SPD react to caress-like touch, which stimulates C-tactile afferents. A standardized touch procedure was used. Seventy females with a primary diagnosis of SPD and 62 healthy females received CT-optimal brushing of their forearms (3 cm/s) and non-optimal brushing (30 cm/s) during an fMRI session. The two types of tactile stimulation were rated according to pleasure, arousal, and urge to pick one’s skin. Relative to healthy controls, patients with SPD showed greater activation in parietal regions (supramarginal/angular gyrus) during CT-optimal touch. Moreover, the deactivation of the middle/ inferior frontal cortex displayed by control participants was absent in the SPD group. Being touched was rated as less pleasant, more arousing, and elicited a greater urge to perform skin-picking in participants with SPD. The mentioned frontal and parietal brain regions are sources of attentional control. They are involved in integrating somatosensory information and switching attention between external/internal stimuli. The present study adds to the limited database on the dysfunctional processing of touch in SPD.

Annotation

The finding:
This study explored fMRI data in skin-picking disorder (SPD) patients vs controls who received caress-like touch, based on the theory that SPD patients have dysfunctional processing of tactile information. The authors found the SPD group had increased activation in the posterior parietal cortex, an area of the brain that integrates somatosensory, auditory, and visual information. The SPD group also demonstrated abnormalities in attentional processes. These findings suggest that the abnormalities associated with altered touch processing in SPD are both at the local and network level.

Strength and weaknesses:
This is a relatively novel investigation as there are few other studies examining this topic. The authors point out that having only female subjects was both a weakness (limiting generalizability) but also a strength (possibly representative of the total population of women with SPD). The study size was relatively small and was underpowered to detect the contribution of comorbidities to the observed findings.

Relevance:
This study furthers the emerging knowledge concerning somatosensory processing in patients with SPD. Additionally, the study findings augment the understanding of the potential therapeutic role of touch in SPD and other mental health disorders which may also have disordered tactile processing.

PUBLICATION #3 — Psychodermatology

Mind and skin: Exploring the links between inflammation, sleep disturbance and neurocognitive function in patients with atopic dermatitis.

Shona Cameron, Ali Donnelly, Conor Broderick, Tomoki Arichi, Ullrich Bartsch, Paola Dazzan, Jesper Elberling, Emma Godfrey, Paul Gringras, Lauren C Heathcote, Desaline Joseph, Tobias C Wood, Carmine Pariante, Katya Rubia, Carsten Flohr.

Abstract: Review Allergy. 2024 Jan;79(1):26-36. doi: 10.1111/all.15818. Epub 2023 Jul 19.

Atopic dermatitis (AD) is a chronic, pruritic and inflammatory, dry skin condition with many known comorbidities. These include airway disease, food allergies, atopic eye disease and autoimmune conditions. Furthermore, there is often significant sleep disturbance as well as increased psychological distress and mental health problems. Severe AD therefore often has a significant impact on the quality of life of both patients and their families. In this review we discuss recent findings on the putative links between AD, its association with itch, sleep disturbance and neuropsychiatric morbidity, including the role of inflammation in these conditions. Itch was thought to predominantly drive sleep disruption in AD. We now understand changes in sleep influence immune cell distribution and the associated inflammatory cytokines, which suggests a bidirectional relationship between AD and sleep. We also increasingly recognize inflammation as a key driver in psychological symptoms and disorders. The link between cutaneous, systemic and possible brain inflammation could at least in part be driven by the sleep deprivation and itch-driven neuronal proliferation seen in AD.

Annotation (unstructured)

This is a review article examining the different mechanisms by which atopic dermatitis (AD) is associated with sleep disturbance and mental health disorders. They identify that inflammation may be the common underlying factor, and each factor in turn impacts and potentially exacerbates the others. The elucidation of these mechanisms offers potential treatment targets to improve outcomes for patients with AD and comorbid psychological disorders.