Alternative Psychotherapeutic Approaches to the Treatment of Eczema

Introduction

Eczema is the most common inflammatory skin disorder, affecting 7.3% of the US adult population.¹ It is a complex condition that manifests as a result of genetic predispositions, innate and adaptive immune response abnormalities, and environmental triggers.² Patients with eczema have a compromised skin barrier, commonly due to filaggrin gene mutation, which disrupts the body’s natural ability to retain moisture and evade allergen and microbe penetration. Consequently, sensitization to allergens and pathogen colonization result in chronically inflamed skin, characterized by pruritus, erythema, and lichenification.² Eczema most often presents during childhood but can persist into adulthood.

One of the predominant features of eczema is chronic pruritus, or itch lasting longer than 6 weeks. Pruritus is not only cited as the most disturbing symptom of eczema but as an exacerbating factor of the disease. Scratching is the method by which patients provide immediate physical and mental relief from pruritus, which reinforces the behavior until it becomes almost automatic or involuntary.³ However, scratching damages the already compromised skin barrier, which worsens inflammation and opens the door for superimposed infections.³ This is often referred to as the vicious itch-scratch cycle of eczema. Moreover, scratching can worsen psychological distress in patients with eczema, as engaging in a knowingly destructive behavior can elicit feelings of anger and low self-esteem.³ The Biopsychosocial Model developed by Verhoeven et al proposes that chronic itch is the manifestation of interacting internal factors (such as personality), external factors (such as environmental stressors), mediating factors (cognitive, behavioral, and social), and physiological factors.⁴ Consequently, a skin disease with a vicious itch-scratch cycle such as eczema may be influenced by an intervention aimed at any one of the above factors. We conducted a literature review to investigate psychotherapeutic options for eczema targeting mediating factors, which include cognitive, behavioral, and social influences.

Methods

A systematic literature search was conducted through PubMed and EMBASE using the search terms “(atopic dermatitis) AND (mindfulness)”, “(atopic dermatitis) AND (psychotherapy)”, “(eczema) AND (mindfulness)”, and “(eczema) AND (psychotherapy)” (Figure 1). We included peer reviewed articles published between 1990 and 2021 written in English. Each article’s content was screened. Original investigative articles that focused on psychotherapeutic interventions for eczema and/or eczema-related psychological morbidities were chosen for further review. Review articles and commentaries were excluded. The chosen articles were organized into seven different categories based on the following primary psychotherapeutic interventions: 1. meditation and mindfulness, 2. stress reduction, 3. habit-reversal training, 4. hypnotherapy, 5. music therapy, 6. massage therapy, and 7. miscellaneous mental health and/or behavior therapy.

Figure 1 Flowchart of the study selection process.

Results

We identified 26 articles involving at least one psychotherapeutic intervention and assessed its impact on eczema and/or eczema-associated psychological symptom(s). The summary of the studies is shown in Tables 1–7.

Table 1 Studies Assessing Meditation and Mindfulness for Eczema

Table 2 Studies Assessing Stress Reduction for Eczema

Table 3 Studies Assessing Habit-Reversal Training for Eczema

Table 4 Studies Assessing Hypnotherapy for Eczema

Table 5 Studies Assessing Music Therapy for Eczema

Table 6 Studies Assessing Massage Therapy for Eczema

Table 7 Studies Assessing Miscellaneous Psychotherapeutic Interventions for Eczema

Meditation and Mindfulness

There were seven studies assessing the benefit of meditation and mindfulness for eczema (Table 1).^5–11 Mindfulness is the quality of intentionally and non judgmentally paying attention to the present moment.¹² Meditation is a technique through which mindfulness can be expressed. In mindfulness meditations, an individual practices the quality of mindfulness by simply being with the self and monitoring one’s internal and external experiences with openness and without any attachments.¹² Mindfulness and meditation are tools to help patients approach their eczema from a different lens.

Xie et al utilized an empirically validated Integrated Body-Mind-Spirit (IBMS) program aimed at children with eczema and their parents.⁸ This program was based on Eastern philosophies of health and well-being, which emphasize treating the whole person and the balance between his/her physical, emotional, and spiritual health, in addition to the person’s relationship to the wider external environment. In this randomized, controlled clinical trial, the treatment group underwent six 3-hour IBMS sessions while the control group was waitlisted to receive the treatment after the study. After the intervention, there was a statistically significant within-group difference for the treatment group, with Scoring Atopic Dermatitis (SCORAD) scores improving from severe to moderate (p< 0.001). There was also a statistically significant improvement in SCORAD in the treatment group compared to the control group (p<0.05). Additionally, the treatment group demonstrated a psychological benefit; anxiety levels (based on the Spence Children’s Anxiety Scale) were statistically significantly decreased at 5 week follow-up compared to pretreatment (p< 0.001) and compared to the control group (p<0.05).

Another randomized, controlled trial by Habib et al displayed similar success.¹¹ The treatment group underwent 6 weeks of a psychoeducational stress management program that included practicing awareness, self-monitoring, control, and relaxation in addition to standard medical therapy; the control group received standard medical therapy alone. After the intervention, subjective ratings of pruritus were statistically significantly reduced for the treatment group compared to the control group, and they remained so at 8 week follow-up (p=0.0022). There was also a statistically significant within-group decrease in the objective global severity of AD for those that underwent treatment (p=0.0339). Lastly, the treatment group displayed a statistically significant reduction in social anxiety compared to the control group (p=0.0092).

Stress Reduction

There were three studies assessing the benefit of stress reduction for eczema (Table 2).^13–15 Methods of stress reduction involve mental and/or physical relaxation. In autogenic training (AT), patients focus on a specific part of their body and say autosuggestions, such as “I am calm and relaxed”, “the itch dissolves”, or “my skin feels cool”.¹³ Another method is cognitive behavioral therapy that emphasizes relaxation.¹³ Progressive muscle relaxation (PMR) training is a more physically involved method of inducing either physical or mental relaxation.¹⁴ The physical component involves tensing and relaxing various muscle groups for a certain amount of time, while the mental component involves focusing on the sensations of tension and relaxation.¹⁴ Regardless of the method used, clinical psychologists often provide the sessions, and patients are subsequently encouraged to continue the practice on their own using guided audio or video recordings.

Ehlers et al performed a randomized controlled trial in order to assess if stress reduction therapy could improve outcomes for patients with eczema.¹³ The study involved one control group receiving standard medical care (SMC) and four treatment groups, which included Dermatologic Education (DE), AT, Cognitive Behavioral Therapy (BT) aimed at stress-reduction, and a combined DEBT group for 12 weekly group sessions, each lasting 1.5–2 hours. The four treatment groups could also use SMC as needed. Compared to pretreatment, all treatment groups displayed statistically significant improvement in the severity of skin lesions (p<0.005) and were superior to SMC (p<0.001 for AT and DEBT; p<0.01 for BT and DE). For eczema-associated distress, all treatment groups showed statistically greater improvement than the SMC group (DE, p<0.01; AT, p<0.05; BT, p<0.05, DEBT, p<0.01). For the Global Disability Rating, psychological and combined treatments were statistically significantly superior to SMC (AT, p<0.01; BT, p<0.05; DEBT, p=0.001).

Bae et al performed a randomized, controlled trial to validate the benefit of PMR for patients with eczema.¹⁴ Patients in the control group received conventional treatment, such as topical emollients and corticosteroids, while those in the PMR group received one month of both physical and mental components of PMR. Both groups demonstrated a statistically significant reduction in the clinical severity of eczema using the Eczema Area Severity (EASI) index. The Visual Analogue Scales (VAS) for pruritus and loss of sleep were statistically significantly improved in the PMR group (p=0.001 and p=0.007, respectively), but not in the control group. Psychological parameters measured by Beck’s Depression Inventory (BDI) and State-Trait Anxiety Index (STAI) were statistically significantly improved in the PMR group, but not in the control group (p=0.016 and p=0.04, respectively).

Habit-Reversal Training

There were two studies assessing the benefit of habit-reversal training (HRT) for eczema (Table 3).^3,16 HRT firstly requires an agreement that the habit needs changing and making an effort to be consciously aware of the behavior.³ Reversing the habit of scratching involves replacing the behavior with a less noxious one, such as clenching the fists for 30 seconds, followed by pressing on or pinching the itchy area until the itching ceases; another method used to keep patients’ hands busy is using a stress relief ball during scratch-triggering activities.^3,16 Each time patients undergo this new behavior in place of scratching, they should receive some form of positive reinforcement.³

In a randomized, controlled clinical trial by Norén et al, patients were divided into two groups: a control group receiving topical mometasone therapy and an intervention group receiving HRT for 8 weeks in addition to instructions on when to periodically start and stop topical mometasone therapy.³ Conversely, the control group was instructed to continue using topical steroids as guided by their prior experiences using them. After the treatment and at 8 week follow up, there was a statistically greater mean improvement in the SCORAD in the treatment group compared to the control group (p=0.027 and p=0.0038, respectively).

A single case study by Valerie Anderson utilized an online HRT program lasting 4 weeks in a 28-year-old patient with severe eczema recalcitrant to topical and oral medication.¹⁶ The patient also suffered from internalized frustration and disappointment due to his scratching behaviors that reportedly occurred regardless of whether or not he felt itchy. After the online program, his self-severity eczema score decreased from 4 to 1, and his Dermatology Life Quality Index (DLQI) reduced from 18 to 4.

Hypnotherapy

There were four studies assessing the benefit of hypnotherapy for eczema (Table 4).^17–20 Hypnotherapy involves guiding a patient into a trance, or an altered state of consciousness, in which greater access to the subconscious is achieved.¹⁷ In this state, patients are more receptive to suggestions, which are defined as ideas offered to the subject for uncritical acceptance.¹⁷ In terms of treating eczema, suggestions that a person’s skin will become “cool and comfortable” may be more effectively accepted as true by the patient. Hypnosis is typically performed by a trained physician, but patients can also be provided with guided audio recordings to complete in a safe place on their own.¹⁷

In one controlled clinical trial by Hájek et al, patients with eczema were compared to healthy controls in cutaneous pain threshold measurements that were performed within a series of 10 hypnotic sessions.¹⁹ Both groups displayed an increase in the cutaneous pain threshold, but the change was more pronounced for patients with eczema. Moreover, the increase in the cutaneous pain threshold in the patients with eczema was associated with symptom improvement, and both these effects correlated with hypnability of the subject (r=0.8).

Another study by Stewart et al sought to assess the benefit of hypnotherapy for both adults and children with AD.¹⁷ Adults underwent anywhere from 2–7 weeks of hypnotherapy sessions that included suggestions of non-scratching behavior and skin comfort/coolness. At the end of the study, patient ratings for itch, scratch, sleep, and tension all statistically significantly improved and remained improved for up to 2 years later (p<0.01). Additionally, use of topical steroids in adults showed a 50% decrease by 8 weeks and a 60% decrease by 16 weeks. In children, the treatment was called “magic music”, which was a nightly audio recording involving suggestions for relaxation, ego strengthening, and skin comfort. Dermatologist assessments of eczema activity, as well as parent/child questionnaires assessing itching, scratching, sleep disturbances, and mood, all improved immediately after the treatment and 2 months later.

Music Therapy

There were two studies assessing the benefit of music therapy for eczema (Table 5).^21,22 The most well-studied technique of music therapy for patients with chronic pain or pruritus involves the U sequence, in which the flow of music follows the shape of the letter U.²¹ The descending arm of the U is characterized by a reduction in tempo, orchestral size, frequency, and volume.²¹ The bottom, flat portion of the U is characterized by relaxing stability, and the ascending arm of the U is re-dynamizing.²¹ The music played can be individualized based on each patient’s music taste.²¹ Patients are typically lying down alone in a dimly lit or dark room with music playing for over 20 minutes.^21,22

In one randomized, controlled trial by Demirtas et al, adult inpatients with a chronic, pruritic skin disease, primarily eczema, were divided into two groups, music intervention group (treatment) and emollient group (control).²¹ At the beginning of patients’ hospital stays, the treatment group listened to individualized music following the U sequence through headphones as they laid in a dark room for 20 minutes. The control group had emollients applied to their entire body instead. After one hour, the treatment group reported a statistically significant reduction in pruritus intensity compared to the control group (p<0.05). Both groups demonstrated a similar decrease in anxiety levels (STAI). Of the patients in the music therapy group, 64% reported feeling an improvement and a desire to continue music therapy, and 91% would recommend the therapy to others who suffer from chronic pruritus.

Hajime Kimata performed a randomized, double blind clinical trial to assess if listening to different musical composers would differently affect allergic responses in patients with moderate eczema.²² All patients were determined to be allergic to latex by positive skin-prick test and positive latex-specific serum IgE. The patients were divided into two groups, one group that listened to Beethoven and another that listened to Mozart. Both groups listened to the music through stereo speakers in a small room for 30 minutes. Skin prick testing (with latex, histamine, and a control solution) demonstrated a statistically significant decrease in skin wheal response induced by latex in the group that listened to Mozart (p<0.001), but not for the Beethoven group. Peripheral blood mononuclear cell samples cultured with latex allergen for 5 days revealed a statistically significant decrease in the production of Th-2 type cytokines (IL-4, IL-10, and IL-13) and a statistically significant increase in Th-1 type cytokines (IFN-g and IL-12) in the Mozart group (p<0.001); listening to Beethoven had no such effect. Additionally, total IgE and latex specific IgE were measured after blood samples were cultured with IL-4, IL-10, anti- CD40 mAb, and latex allergen for 14 days; levels did not change in the Beethoven group, but both were statistically significantly reduced in the Mozart group (p<0.001). The last victory for Mozart over Beethoven lies in the psychological parameter–in a one-item stress rating scale, a statistically significant reduction was measured for the Mozart group (p<0.001), while there was no change for those who listened to Beethoven.

Massage Therapy

There were two studies that assess the benefit of massage therapy for eczema (Table 6).^23,24 In massage therapy, a licensed massage therapist often demonstrates the first few sessions so that the patient’s care provider can subsequently perform the technique at home.²³ Massage can either be done in short (10 minute), daily sessions when done at home, or in longer, weekly sessions when performed by a licensed massage therapist. The exact technique of the massage varies, but it is often broken down based on the region of the body massaged and the directionality of the strokes.²³

In a controlled clinical trial by Schachner et al, children were divided into two groups, a control group that received SMC (emollients and topical steroids) and a treatment group that received massage therapy in addition to SMC.²³ A massage therapist demonstrated a 20 minute massage on the child, and then the parents performed it daily for one month. The treatment group demonstrated a statistically significant improvement in all dermatologist-assessed measures of focal eczema lesions (redness, p<0.001; lichenification, p<0.05; scaling, p<0.05; excoriation, p<0.01; pruritus, p<0.05). Only scaling also statistically significantly improved for the control group (p<0.05). For the global skin assessment by dermatologists, scaling and excoriation statistically significantly improved for the treatment group whereas only scaling statistically significantly improved for the control group (p<0.05). Parent-rated psychological parameters showed statistically significant improvement in child anxiety (p<0.01) and stability (via the Coping Index) (p<0.05) and in the How I Feel About My Child Scale (p<0.05) for only the treatment group. For the Behavior Observation Scale, which was measured by researchers blinded to the study hypothesis and child groups, only children in the treatment group displayed a statistically significant improvement, specifically in mood, activity level, and anxiety (p<0.05). Lastly, only in the treatment group did the parents’ own STAI statistically significantly improve (p<0.05).

Miscellaneous Psychotherapeutic Interventions for Eczema

There were six studies that assessed miscellaneous therapies to improve mental health and behavior in people with eczema (Table 7), including standard psychological treatments, such as cognitive behavioral therapy, psychotherapy, and a constellation of psychological treatments.^25–30

Evers et al performed a prospective, controlled clinical trial testing the benefit of a constellation of psychological treatments for patients with eczema.²⁷ The treatment group received a program of cognitive behavioral therapy, relaxation, development of coping skills, and HRT for 4 sessions, while the controls were waitlisted for the program. After treatment and at 12 month follow-up, all eczema and eczema-associated psychological outcomes were statistically significantly improved in the treatment group compared to the control group (p<0.05).

Linnet et al performed a randomized, controlled trial to assess the benefit of dynamic psychotherapy for patients with eczema.²⁵ The treatment group underwent dynamic psychotherapy that focused on illness perception for 6 months in addition to SMC while the control group only received SMC. There were no significant differences in objective SCORAD, STAI, or treatment adherence between the groups before and after treatment. However, the authors found that an initial high trait anxiety created an attrition bias for treatment adherence, such that those in the control group with high initial anxiety were statistically significantly more likely to discontinue treatment (p<0.05). They also found that an initial high state anxiety was a statistically significant predictor for improvement in STAI and objective SCORAD for those that received psychotherapy (p<0.05), accounting for 27% of the variance in STAI scores and 76% of the variance in objective SCORAD.

Discussion

The psychosocial burden in patients with eczema is high and is dependent on the level of pruritus.^25,31 A survey-based study comprised of 4744 adolescents from the general Norwegian population found that those suffering from chronic pruritus are significantly more likely to experience suicidal ideation compared to the general population, and they experience it at an equal magnitude to those suffering from chronic pain.³² The relationship between eczema and psychological symptoms is not one-sided, as heightened stress is identified by more than half of patients as a trigger for an eczema exacerbation.³¹ In addition to the pathophysiological effects of stress, psychosocial burdens impact the way in which patients interact with their diseases and the therapeutic options presented to them.

A comprehensive review of the literature demonstrates that psychotherapeutic interventions can be beneficial, both physically and mentally, for patients with eczema. Itch catastrophizing, a debilitating feature of the disease, is negatively correlated with mindfulness scores.³³ Thus, implementing holistic, Eastern medicine practices successfully improves outcomes in patients with eczema.⁸ Similarly, as stress and eczema reciprocally worsen each other, treatment plans involving stress-reduction are superior to those that do not.¹³ Stress reduction and mindfulness can also be combined to improve itch intensity and associated emotional distress.⁷ Music therapy, in addition to relieving pruritus, results in patient-perceived improvement in eczema, which can restore hope and encouragement in patients’ efforts toward healing.²¹ Massage therapy, the experience of relaxing skin-to-skin contact, may aid in the sensitization and aversion to touch that many children with eczema endure.²³ Lastly, traditional psychological therapies can be added to the above interventions. For example, meditation, hypnosis, imagery, and art can be effectively combined with psychodynamic and CBT.³⁰

The mechanisms by which the above therapies are helpful for patients are complex, as are the biological processes that lead to chronic pruritus. For instance, hypnotherapy has been shown to help patients by means of decreasing cutaneous sensitivity, and music therapy has been shown to decrease serum cortisol and inflammatory cells counts.^19,21 These biological processes, and their relevancy to the skin, are explained in what is called the neuro-immuno-cutaneous-endocrine (NICE) system.³⁴ NICE describes the skin as an active neuro-immuno-endocrine interface, rather than a static organ, that maintains homeostasis via multidirectional communication with NICE organ systems.³⁴ This framework may provide the underlying reasons why the aforementioned therapies could impact the course of eczema in a patient’s life. Patients with eczema have overactive sympathetic nervous systems, both in stressful and non-stressful settings.³⁵ Sympathetic system dysfunction, via the release of acetylcholine (ACh) from cutaneous autonomic nerve fibers, triggers pruritus.³⁶ ACh activates muscarinic receptors on keratinocytes, and an intradermal injection of ACh has been shown to provoke a primarily pruritic response in atopic lesions compared to pain in normal skin.³⁶ Conversely, increasing vagal tone inhibits experimentally-induced pruritus via a histamine-independent mechanism.³⁵ Patients with eczema, however, display rigidity in their parasympathetic responses. This limits their bodies’ inhibition of pruritus and adaptability to stressful situations.³⁵ Moreover, parasympathetic dysfunction decreases patients’ responses to anti-inflammatory medications.³⁷ This suggests that not only does autonomic dysfunction exacerbate the sensation of pruritus, it might also limit an individual’s response to treatment efforts. Training patients with eczema in mindfulness-based or other stress-reducing strategies may curb their sympathetic overdrive, resulting in more harmonious autonomic activity in the skin and improved responses to SMC.

Although there are many adjunctive psychotherapeutic modalities available for patients with eczema, the implementation of such techniques requires a certain level of discretion from the provider. Although psychological therapy does not need to be distributed to all patients, failing to offer it to select patients may worsen outcomes, for example, by decreasing compliance to SMC.²⁵ Furthermore, mindfulness can result in people experiencing a shift toward re-perceiving uncomfortable internal and external states prior to the transformation of those states. As individuals with eczema experience high levels of physical and emotional discomfort, mindfulness may result in an enhanced awareness of those happenings. One protective measure for such patients could be hypnotherapy, in which repressed thoughts can be accessed in a controlled environment and provide real-time substance for therapy.¹⁷

Ultimately, the benefit of psychotherapeutic interventions for eczema and its psychological comorbidities is a flourishing, though incomplete, area of research. One limitation of our review is that some of the interventions mentioned have very few trials assessing their validity. On the other hand, the validity of such treatments may be underestimated in the literature. Moreover, standardized guidance on how to identify candidates for these treatments does not currently exist, nor do the means by which these methods can be administered. Research is needed as to how psychological therapy can be tactfully allocated and readily available avenues to care. The lack of standardized guidance may serve as a potential barrier to offering these treatments to patients, and this may be detrimental to patient acceptance of SMC and the extent to which they can experience an enhanced quality of life.

Conclusions

A review of the current literature demonstrates that there are several promising psychotherapeutic interventions for eczema and eczema-associated psychological symptoms. The interaction between eczema and mental health is complex and reciprocal. Providers should consider incorporating alternative, psychologically therapeutic avenues into a patient’s treatment plan to improve their symptoms. Further research is needed to better explore such interventions and to properly guide clinicians on when and how to implement them.