PracticalDermatology

Psycho-cutaneous therapy is a concept that stems from the complex interplay between the skin and the nervous system. The two seemingly dissimilar systems have embryonic origins that are closely linked in their formation and development. The neuroectoderm, the precursor to the nervous system, is formed alongside the cutaneous ectoderm that becomes the skin. The relationship between the two systems is complicated and not fully understood. However, it can be appreciated in instances such as when touch, temperature, pressure, or vibration sensors in the skin send inputs to the nervous system that then feedback to the skin to create changes such as variations in blood flow and constriction of arrector pili muscles. It is due to this interconnectivity that hypnosis was first hypothesized to have potential to treat cutaneous pathology.

Hypnosis was famously described by Marmer in 1959 as a psychophysiological state of altered consciousness that consisted of narrowed awareness, restricted and focused attentiveness, selective wakefulness, and heightened susceptibility. Hypnosis leads to an individual creating an inner vivid reality from their imagination. Under hypnosis, people are susceptible to suggestions from others, their environment, or their own mind. This state of mind makes it so that suggestion can alter one’s perception and memory, as well as their physiologic processes.

Although there are a variety of methods to induce and use hypnosis for the treatment of dermatologic disease, the most popular techniques involve supportive ego-strengthening therapies, such as positive suggestion. During such therapy, a patient is induced into a hypnotic state and then suggested positive results or feelings about their condition. This process can be so powerful that studies have even shown localized blisters can be produced by hypnotic suggestion alone.

The mechanism by which hypnosis is effective is still hypothesized. It is known that blood flow regulation and other autonomic functions can lead to changes in neurohormonal systems. Through hypnosis, it is suggested that patients may learn how to alter autonomic responses and establish habit patterns that can improve cutaneous symptoms. Psoriasis may serve as an example to demonstrate this notion, as there have been several studies linking stress and psoriasis flares. It is theorized that in a patient exhibiting a pathology, certain organs may be particularly susceptible to anxiety and autonomic response. Therefore, increased anxiety leads to dysfunctional autonomic function, resulting in skin manifestations. In the case of psoriasis, these would be the lesions typically seen with flares. Psychological techniques, such as hypnosis, have been shown to alter the activity of the autonomic nervous system, which in turn affects immunologic processes that lead to lymphocytic actions that make patients vulnerable to dermatologic disease like psoriasis.

Another mechanism by which hypnosis is proposed to work is by altering blood flow, and therefore activity in particular brain regions. Pain reduction during hypnosis has been linked to the reduction of activity in the mid anterior cingulate cortex by monitoring of EEG and PET scans during procedures. While there is still much mystery around how the mind and skin are connected and how this link can be exploited by therapies such as hypnosis, studies are slowly revealing findings that may help to unlock the mechanism. Perhaps this will make it possible to one day perfect the therapy and show even more impressive results.

Up to 69 percent of patients with dermatologic disease have used complementary or alternative medicine in their lifetime. With patient interest in these therapies growing, it is essential that clinicians expand their knowledge of alternative, complementary, and integrative approaches. Familiarity with such treatment options has the potential to increase patient satisfaction and help physicians ensure quality and safety of these types of procedures. Hypnosis is among these therapies.

Hypnosis has shown promising results for patients who have had difficulty responding to more conventional therapies. In a variety of diseases where conventional therapies such as topical medications have failed to show results, hypnotherapy has managed to provide lasting effects in select cases. It has also shown a reduction of relapse rates of symptoms in some populations. For instance, studies have shown impressive results for patients receiving hypnotherapy for warts or alopecia areata. These patients had decreased symptoms for longer periods of time compared to conventional therapies.

An additional dimension is that hypnosis can involve patients in their treatment process in another way. Practitioner-induced hypnosis can often be supplemented with home exercises that can bolster the effects of the original treatment. For example, when patients are given positive suggestions under hypnosis, they are often encouraged to self-induce hypnosis at home with recordings or try to meditate and repeat the positive suggestions in order to strengthen the effect of the clinic-based hypnotherapy. Patients often express a desire to be a part of their therapeutic journey, and hypnotherapy is one therapy in which they can play an active role. Such involvement may actually increase patient satisfaction with their treatment.

While hypnosis benefits from being performed by a licensed practitioner, it can still be less expensive than many conventional therapies. Unfortunately, this cost is often not covered by insurance, making the final cost to the patient higher. Another potential drawback is time commitment for the sessions themselves as well as the commute. However, while hypnotherapy may appear time consuming, time requirements for screening and educating patients on conventional therapies are actually comparable to the time taken for hypnotherapy.

Although evidence for this approach has been inconsistent, there is an increasing trend towards randomized controlled trials that may further elucidate the optimal role of hypnotherapy in dermatology. The growing knowledge base around hypnosis has shown promising results in a variety of dermatologic diseases, including verruca vulgaris, psoriasis, atopic dermatitis, urticaria, alopecia areata, herpes simplex, hyperhidrosis, rosacea, vitiligo, and acne excoriée, among others. With its relative safety and promising results for a variety of patients, hypnosis has the potential to become a more viable option for treating dermatologic conditions.

Patient Selection for Hypnosis Treatment

Hypnotherapy has demonstrated various levels of success in patients. While some of the variability may be due to the hypnosis itself or the practitioner skill level at inducing hypnosis in a patient, part of this inconsistency may stem from individual patient hypnotizability. Studies have shown that individuals are usually consistent in their level of hypnotizability over time, suggesting a set susceptibility to hypnosis. Data suggest that this may be linked to gene alleles for catechol-O-methyltransferase. Homozygous valine alleles are associated with a four times faster degradation of dopamine and, as a result, lower hypnotizability. On the other hand, homozygous methionine alleles lead to people having slower dopamine degradation, which appears to make them easier to hypnotize. Alternative methods for assessing potential hypnotizability of patients have been proposed. Among them is a Hypnotic Induction Profile that is a 16-point scale placing patients in different levels of hypnotizability. The most successful treatments are for those with medium to high hypnotizable scores.

In general, children seem to be more easily and consistently hypnotizable. In fact, some pediatric studies have shown better long-term results when compared to adult trials using hypnosis-based treatment. Children require less advanced hypnosis induction techniques and can even be guided into meditation by being instructed to imagine watching television.

Promising Hypnosis Results

Promising results from hypnosis treatments have been seen in a variety of dermatologic diseases. We will explore some of the diseases that have shown most consistent results.

Verrucae. Perhaps the disease most successfully proven to benefit from hypnotherapy is verrucae. While many other diseases have shown efficacy of hypnotherapy in individual cases, the treatment of warts with hypnotherapy has been studied in randomized control trials. Published studies show, on average, between 27-55 percent success rates in treating warts using hypnosis. One such study showed that 53 percent of patients who received hypnotherapy showed improvement in three months after five sessions. Control patients who received no therapy showed no improvement. Another study showed that compared to traditional topical salicylic acid and placebo, all subjects in the hypnosis group lost more warts. A follow-up trial included a placebo that involved passive sessions where hypnosis did not occur, but a description of the treatment of warts was performed. This trial highlighted that patients who actively participated in hypnosis techniques where they imagined their verrucae tingling, shrinking, and disappearing, demonstrated a statistically significant improvement in symptoms. Hypnosis is an active process that requires patients who are able to be hypnotized successfully in order to show results.

Although a number of studies have shown interesting effects of hypnotherapy on wart treatment, these results have been unreproducible or inconsistently reproduced in other trials. One such study demonstrated that suggestion under hypnotherapy aimed at one side of the body showed loss of warts only one side of the subject in nine out of 10 patients involved in the study. The remaining patient lost warts on both sides. Although this would point to the degree of suggestible power under hypnosis and how specific hypnosis treatment could be, five other studies have failed to replicate these results. However, most of these studies had relatively poor methodology, making them easy to call into question. Another trial that had unreproducible results pointed to a greater propensity of females showing improvement of verrucae under hypnotherapy. This could point to a subgroup of patients who may be more highly susceptible to hypnosis-based treatments and warrants further exploration.

Atopic Dermatitis. The goal of hypnotherapy in atopic dermatitis centers around the reduction of itching and scratching, which leads to exacerbation of the disease. There are many treatments for atopic dermatitis, but topical corticosteroids remain a cornerstone of therapy. One study compared topical corticosteroids to hypnotherapy and showed that there was a greater reduction in itching, scratching, and sleep disturbances compared to the corticosteroid patients. There was also a 60 percent reduction of corticosteroid use in hypnotherapy-treated patients at 16 weeks. Another study focused on patients who were resistant to conventional therapy for their treatment of atopic dermatitis. Hypnotherapy again showed a statistically significant benefit (P < 0.01) for these difficult-to-treat patients.

In children resistant atopic dermatitis treated by hypnosis led to immediate relief in levels of itchiness, scratching, and sleep disturbance following treatment in 90 percent of trial patients. Interestingly, this effect seemed to last 18 months after treatment in the majority of patients. Although this study showed quite impressive results, the study only included 20 subjects each with a particularly high disease symptom burden. For patients in which conventional therapies for atopic dermatitis have failed, studies point to hypnotherapy serving as a potentially viable adjunct to their treatment to consider.

Pain. Several meta-analyses have shown efficacy for hypnosis in relieving pain in patients with a variety of painful conditions including headache, burn injury, heart disease, cancer, dental problems, and chronic back issues. Remarkably, it has shown efficacy in providing analgesia for radiologic procedures and even surgery. In dermatologic conditions specifically, pain associated with eczema, post-herpetic neuralgia, and dermatologic surgical procedures has also shown to be effectively treated with hypnosis. Hypnotherapy can be used to reduce needle phobia and anxiety associated with dermatologic procedures. One study showed that during a procedure pain levels remained flat under hypnosis while control groups experienced a linear increase in pain. For patients with high levels of anxiety, low pain tolerances, or allergies to pain medications, hypnosis could serve as a promising treatment option.

Psoriasis. Although the psyche alone rarely causes dermatologic pathology, mental states can impact skin disorders. It is generally accepted that emotional stress can influence many cutaneous diseases such as psoriasis, seborrhea, and atopic dermatitis. Recent studies show results that are in line with this notion.

Controlled trials of highly hypnotizable psoriasis patients who have a high emotional trigger component to their disease, showed up to 75 percent of clearing of their skin using hypnotherapy. These results may indicate that other cutaneous disease with psychologic components such as those with emotional triggers may benefit from hypnotherapy the most.

Raynaud’s Phenomenon. In the treatment of Raynaud’s phenomenon, there is evidence pointing to hypnosis enhancing the effects of biofeedback treatment. Biofeedback can help treat skin pathology that have an autonomic nervous system component. Studies using instruments that measure galvanic skin resistance (GSR) and skin temperature have shown that patients with systematic sclerosis with Raynaud’s Phenomenon can increase skin temperature at an average of 4^oC under hypnosis with biofeedback training. Patients showed significantly greater elevations in finger blood flow, finger temperature, and GSR conductance compared with those not under hypnosis. Similar results have been seen in patients with other skin disorders that have an autonomic nervous system component such as hyperhidrosis. Future studies will likely expand to include even more diseases that could fall under this category.

Conclusion

There are a number of promising studies that provide evidence for the efficacy of hypnotherapy for a variety of dermatologic conditions. However, much of the favorable data is based on small studies that would benefit from further validation by large-scale trials. With more research, perhaps the mechanism of hypnotherapy could be better understood and, with this knowledge, the methodology improved to optimize results. Thus far, the evidence is compelling for the treatment of dermatologic diseases that have been hypothesized to have a psycho-cutaneous aspect. Given the putative mechanism of hypnotherapy, there is hope that it can be adapted in order to aid in the treatment of more conditions that exhibit this same link.

REFERENCES AND FURTHER READING

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