Psychoneuroimmunodermatology of atopic dermatitis: from empiric data to the evolutionary hypothesis

Mental health impairment among children with atopic dermatitis: A United States population-based cross-sectional study of the 2013-2017 National Health Interview Survey

BACKGROUND

Atopic dermatitis (AD) is associated with mental health disorders, but its impact on global mental health symptoms is less clear.

OBJECTIVE

To determine the association between pediatric AD and mental health impairment.

METHODS

In a cross-sectional study using 2013-2017 United States National Health Interview Survey data, children with and without AD were assessed for mental disorder with impairment (MDI) using a validated behavioral screening questionnaire. Mental health services utilization was also reported.

RESULTS

The prevalence of any MDI was 26.7% (95% confidence interval [CI], 25.1-28.3) among children with AD and 17.7% (95% CI, 17.2-18.2) among those without AD, with severe MDI being present in 10.9% (95% CI 9.9-12.1) and 6.2% (95% CI 5.9-6.5), respectively. Adjusted for sociodemographic factors, AD was associated with higher odds of MDI (odds ratio, 1.52; 95% CI, 1.39-1.67), including impairments in conduct, emotions, peer relationships, and attention. Among children with AD, 19.9% (95% CI, 16.6-23.8) and 53.5% (95% CI, 48.5-58.5) of those with mild or severe MDI, respectively, had seen a mental health professional in the last year.

LIMITATIONS

Misclassification bias may arise from self-reported data.

CONCLUSION

AD is associated with clinically significant mental health symptoms, but many affected children may not seek or receive care for their symptoms.

Health-related Quality of Life and Mental Health of Adults With Atopic Dermatitis

AIM

This cross-sectional study aimed to examine the association between the prevalence of atopic dermatitis in Korean adults and their health-related quality of life and mental health.

METHODS

Data from a nationally representative sample of 11,913 adults who participated in the Korea National Health and Nutrition Examination Survey V (2010-2012) were analyzed by using SAS version 9.3.

RESULTS

The adults with atopic dermatitis had significantly lower quality of life and higher stress than did those without it. Moreover, the health-related quality of life of the adults with atopic dermatitis was significantly lower than those without the disease, after adjusting for all covariates. The adjusted odds ratios of the adults with atopic dermatitis were 1.74 (95% confidence interval [CI]: 1.14-2.65) for stress, 1.69 (95% CI: 1.00-2.84) for depression, and 1.66 (95% CI: 1.02-2.69) for suicidal ideation.

CONCLUSION

Improving our understanding of atopic dermatitis should help nurses and patients manage the stress, depression, suicidal ideation, and reduced quality of life associated with this chronic disease. There is a need to develop and conduct intervention of programs for improving mental health as well as clinical aspects of adult atopic dermatitis.

Psycho-emotional conditions of patients with non-cicatrazing alopecia (circumsribed, androgenetic)

Most common psycho-emotional disorders are described with patients with circumsribed, androgenetic alopecia. Main identification methods presented. It was shown based on analysis of literary data and in order to upgrade the quality of medical help for this group of patients how important it is to identify the preoccupying, depressive and other pathological psychogenic conditions of patients chronic alopecia.

Prevalence rate and factors associated with atopic dermatitis among Korean middle school students

PURPOSE

The purpose of this study was to verify prevalence rates of atopic dermatitis (AD) in middle school students in Korea and to define AD and associated factors.

METHODS

This study was conducted using secondary analysis of raw data from the 'The 6th Korean National Adolescent Health Behavior Survey, 2010' conducted by the Korea Centers for Disease Control. The participants were 37,570 students. General characteristics and health behavior-related characteristics were analyzed using descriptive statistics, χ²-test and logistic regression analysis.

RESULTS

Results are as follows. 1. There were 8,494 middle school students (22.6%), who had been diagnosed with AD during the last 12 months. 2. Factors associated with AD in middle school students were gender (p<.001), grade level (p=.001), father's education (p<.001), mother's education (p=.032), regular dietary habits (breakfasts, p=.025; lunches; p=.003), stress (p<.001), recognition of subjective awareness of one's health conditions (p<.001), hand washing before meals at school (p=.013), and cessation education for both smoking (p=.002) and alcohol (p=.031).

CONCLUSION

Results of the study indicate that in order to alleviate AD symptoms in these students, there is a need to develop nursing interventions and education programs taking into consideration these variables and verifying the effects of interventions and programs.

Stress involvement as trigger factor in different skin conditions

Dermatological conditions are intimately related to stress. There was a great interest in this field in the last years. Stress could be involved as a trigger factor for a lot of cutaneous diseases: alopecia areata, psoriasis, vitiligo, lichen planus, acne, atopic dermatitis, urticaria. For other conditions: seborrheic dermatitis, hyperhydrosis, herpes, pemphigus, a.s.o, there are anecdotal notices. On the other hand, the skin disease itself could induce a secondary stress for the patient, influencing his quality of life. The stress per se is less important than the “perceived stress”, the patient’s perception of the stressful situation. This perception could be influenced by the psychological state of the patient. Anxiety, depression could change the perception of the event. It is important to take care of these aspects during the consultation. A good cooperation with psychiatrist or/and psychologist could improve the results, besides the specific therapy.

Mild exercise suppresses exacerbation of dermatitis by increasing cleavage of the β-endorphin from proopiomelanocortin in NC/Nga mice

This study investigated the mechanism by which the strength and weakness of exercise stress affects the skin symptoms of atopic dermatitis (AD). Specific pathogen-free (SPF) and conventional NC/Nga mice were used. Conventional mice, but not the SPF, spontaneously develop dermal symptoms similar to that of patients with AD. There were two types of stress, mild (20 m/min for 60 min) or strong exercise (25 m/min for 90 min), using a treadmill four times per day. The symptom of the conventional group were strongly exacerbated by strong exercise but ameliorated by mild exercise. The plasma concentrations of α-melanocyte stimulating hormone (α-MSH) and the expression of melanocortin receptor-1 in skin elevated after strong exercise but decreased after mild exercise. The plasma levels of β-endorphin and the expression of µ-opioid receptor in skin were increased by mild exercise. In addition, the expression of prohormone convertase (PC) 1/3, PC2 and carboxypeptidase E (CPE) in pituitary gland were higher in the conventional group than in the SPF group. The level of PC2 was suppressed by mild exercise in the conventional groups, and elevated further by strong exercise. The level of PC1/3 becomes higher with the increase of the exercise load. On the other hand, the expression of the CPE was further increase by mild exercise but suppressed by strong exercise. These observations suggested that exercise-induced stress significantly affect the symptoms of AD in a pivotal manner depending on the levels of α-MSH and β-endorphin, and the expression of pituitary PC2 and CPE.

Mild exercise suppresses exacerbation of dermatitis by increasing cleavage of the β-endorphin from proopiomelanocortin in NC/Nga mice

This study investigated the mechanism by which the strength and weakness of exercise stress affects the skin symptoms of atopic dermatitis (AD). Specific pathogen-free (SPF) and conventional NC/Nga mice were used. Conventional mice, but not the SPF, spontaneously develop dermal symptoms similar to that of patients with AD. There were two types of stress, mild (20 m/min for 60 min) or strong exercise (25 m/min for 90 min), using a treadmill four times per day. The symptom of the conventional group were strongly exacerbated by strong exercise but ameliorated by mild exercise. The plasma concentrations of α-melanocyte stimulating hormone (α-MSH) and the expression of melanocortin receptor-1 in skin elevated after strong exercise but decreased after mild exercise. The plasma levels of β-endorphin and the expression of µ-opioid receptor in skin were increased by mild exercise. In addition, the expression of prohormone convertase (PC) 1/3, PC2 and carboxypeptidase E (CPE) in pituitary gland were higher in the conventional group than in the SPF group. The level of PC2 was suppressed by mild exercise in the conventional groups, and elevated further by strong exercise. The level of PC1/3 becomes higher with the increase of the exercise load. On the other hand, the expression of the CPE was further increase by mild exercise but suppressed by strong exercise. These observations suggested that exercise-induced stress significantly affect the symptoms of AD in a pivotal manner depending on the levels of α-MSH and β-endorphin, and the expression of pituitary PC2 and CPE.

Psychodermatological disorders: recognition and treatment

Many dermatological disorders have a psychosomatic or behavioral aspect. Skin and brain continually interact through psychoneuroimmunoendocrine mechanisms and through behaviors that can strongly affect the initiation or flaring of skin disorders. It is important to consider these mind-body interactions when planning treatments for specific skin disorders in individual patients. Mind-influencing therapeutic options that can enhance treatment of skin disorders include standard psychotropic drugs, alternative herbs and supplements, the placebo effect, suggestion, cognitive-behavioral methods, biofeedback, and hypnosis. When individual measures do not produce the desired results, combinations of drugs or addition of non-drug therapies may be more successful. Psychophysiological skin disorders may respond well to non-drug and drug therapies that counteract stress. Treatment of primary psychiatric disorders often results in improvement of associated skin disorders. Psychiatric disorders secondary to skin disorders may also require treatment. Therapeutic options for each of these are discussed.

Autoimmune markers in vitiligo patients appear correlated with obsession and phobia

BACKGROUND

Current studies have treated a limited portion of the subjective aspects of vitiligo patients and have yet to elucidate possible psychological differences between those with autoimmune markers (AIM) with respect to those without autoimmune markers (NAIM).

OBJECTIVE

To perform an age and gender-matched 1:1 case-control study through a comparison of non-segmental vitiligo patients with autoimmune features vs. those without autoimmune features in regards to psychiatric features, psychosomatic aspects and social parameters.

METHODS

A total of 112 non-segmental vitiligo patients have been examined at the Florence University dermatology outpatient service (2nd dermatology unit). Vitiligo with an autoimmune background was defined by the presence of autoimmune antibodies and/or autoimmune diseases. Psychiatric screening was performed by dermatologists using the modified Middlesex Healthcare Questionnaire (MHQ); psychosomatic aspects and social impact were analysed with a standardized, Florentine questionnaire.

RESULTS

Upon performing a conditional regression model, age, phobia and obsession were significantly predictive of the presence of AIM and a low total MHQ score was significantly predictive of NAIM in vitiligo patients. With univariate analysis, we found significant differences in: identifiable stress related to the onset of vitiligo, vitiligo triggered by stress, and modified interpersonal relationships related to vitiligo, which were associated with the subgroup containing autoimmunity markers.

CONCLUSIONS

We found a higher prevalence of age, obsession and phobia among vitiligo patients AIM as compared to vitiligo patients NAIM. Thus, in the presence of demonstrated autoimmunity, screening for particular psychiatric aspects may be useful in the clinical practice of vitiligo.

Strong exercise stress exacerbates dermatitis in atopic model mice, NC/Nga mice, while proper exercise reduces it

Atopic dermatitis is well known to exacerbate by stress. How the influence of exercise stress on the skin symptoms in patients with atopic dermatitis has not been clarified. The purpose of our research is to investigate how different strength of exercise stress acts on atopic dermatitis. Specific pathogen-free (SPF) and conventional NC/Nga male mice were used for the experiments. Conventional mice but not SPF group spontaneously develop dermal symptom similar to that of patients with atopic dermatitis at their age of 7 weeks. They were given two types of stress, mild (20 m/min for 60 min) or strong exercise (25 m/min for 90 min), using a treadmill four times per day. The dermal symptom of the conventional group was strongly exacerbated by strong exercise but ameliorated by mild exercise. Under the standard experimental conditions, plasma concentrations of α-melanocyte-stimulating hormone (α-MSH), transforming growth factor-β (TGF-β) and substance P in conventional mice increased markedly with concomitant exacerbation of the symptom. The plasma concentrations of these proteins elevated after strong exercise but decreased after mild exercise. Under the conventional conditions, plasma levels of β-endorphin increased with time by some mechanisms enhanced by the mild exercise. These observations suggested that exercise-induced stress significantly affect the symptom of atopic dermatitis in a pivotal manner depending on the plasma levels of TGF-β, α-MSH, substance P and β-endorphin.

Eosinophilic ulcer: the role of stress-induced psychoneuroimmunologic factors

INTRODUCTION

Eosinophilic ulcer (EU) is a rare pathology and its etiology is still slightly known. It is a benign lesion characterized by fast-growing ulceration with elevated and indurated borders, most commonly affecting the tongue.

CASE REPORT

The authors describe a case of EU on a lingual border that was initiated and had its clinical behavior altered by the psychological stress the patient was experiencing.

DISCUSSION

This paper discusses the stress effects that alter the individual's immunologic response, thus attracting mast cells and eosinophils towards the mucosal epithelium, which are involved in eosinophilic ulcer. The authors make an association between eosinophilic ulcer and atopic dermatitis, two diseases that appear to have a similar, though not fully defined, etiology. The psychological stress factor was considered a predisponent factor for eosinophilic ulcer etiology and its interference in the etiology and evolution of this disease should be considered.

Psychological interventions in the management of common skin conditions

The nervous system and the skin develop next to each other in the embryo and remain intimately interconnected and interactive throughout life. The nervous system can influence skin conditions through psychoneuroimmunoendocrine mechanisms and through behaviors. Understanding the pathophysiology aids in selection of treatment plans for correcting the negative effects of the psyche on specific skin conditions. Medication options include standard psychotropic medications and alternative herbs and supplements. Other options include biofeedback, cognitive-behavioral methods, hypnosis, meditation, progressive relaxation, the placebo effect, and suggestion. When simple measures fail, combining medications with other therapeutic options may produce better results. Skin conditions that have strong psychophysiologic aspects may respond well to techniques such as biofeedback, cognitive-behavioral methods, hypnosis, meditation, or progressive relaxation that help to counteract stress. Treatment of primary psychiatric disorders that negatively influence skin conditions often results in improvement of those skin conditions. Abnormal conditions of the skin, hair, and nails can also influence the psyche negatively. Treatment of secondary psychiatric disorders such as anxiety or depression that are triggered or exacerbated by the appearance of these skin conditions or the associated discomfort may also be required.

Neuropsychologic status at the age 4 years and atopy in a population-based birth cohort

BACKGROUND

Mental health has been reported to be associated with allergy, but only a few cohort studies have assessed if neurodevelopment predicts atopy.

OBJECTIVE

To investigate if neurobehavioral status of healthy 4-year-old children was associated with specific immunoglobulin E (IgE) at the same age and skin prick test results 2 years later.

METHODS

A population-based birth cohort enrolled 482 children, 422 of them (87%) provided neurobehavioral data, 341 (71%) had specific IgE measured at the age of 4 years; and 395 (82%) had skin prick tests completed at the age of 6 years. Atopy was defined as IgE levels higher than 0.35 kU/l to any of the three tested allergens at the age of 4 or as a positive skin prick test to any of the six tested allergens at the age of 6. McCarthy Scales of Child Abilities and California Preschool Social Competence Scale were the psychometric instruments used.

RESULTS

Twelve percent of children at the age of 4 and 17% at the age of 6 were atopic. Neurobehavioral scores were negatively associated with 6-year-old atopy after adjustment for socio-demographic and allergic factors, A relative risk of 3.06 (95% CI: 1.30-7.24) was associated with the lowest tertile (scorings < or =90 points) of the general cognitive scale. Similar results were found for verbal abilities, executive functions, and social competence. Asthma, wheezing, rhinitis, and eczema at the age of 6, but not at the age of 4, were associated with neurodevelopment at the age of 4.

CONCLUSIONS

Neuropsychologic functioning and later atopy are negatively associated in preschool age children.

Atopic dermatitis

Atopic dermatitis (AD) is a common dermatologic disease that can occur at different ages with different clinical manifestations. The etiologic factors and the pathogenetic pathways of AD have been thoroughly investigated but as often happens, something more has to be yet elucidated before the statement, that we possess the overall comprehension of the disease, could be considered the truth. Treatment of AD is often challenging, because of the chronic course of the disease and the fact that even the best of therapies is affected by adverse events, intolerances, or the possible occurrence of contraindications resulting from a sudden change in the overall health status of the patient (e.g., the onset of some comorbidities). Hence, the need to know "how, when, with what, and why" to treat AD patients with the many therapeutic modalities is now in the hands of the dermatologists.

Prurigo nodularis and lichen simplex chronicus

Emotional tensions in predisposed subjects may play a key role in inducing a pruritic sensation, leading to a scratching that, becoming a self-perpetuating pathomechanism, may represent the main feature of two distinct cutaneous clinical entities: prurigo nodularis and lichen simplex chronicus. Psychogenic factors play a relevant role in both conditions, and they are often associated with depression and dissociative experiences. Hence, the importance of the evaluation of these patients from the point of view of psychodermatology, which may analyze the relationship between skin disease and psychological factors. Patients with real or perceived imperfections in particular areas of the body (face, scalp, hands, and genital area) are more prone to psychologic distress, whereas cutaneous diseases may lead to experience a heightened level of distress. As psychosomatic factors have been estimated to be present in at least one-third of dermatologic patients, effective management of skin conditions involves consideration of the associated emotional factors.

Further exploring the brain-skin connection: stress worsens dermatitis via substance P-dependent neurogenic inflammation in mice

A neurogenic component in atopy and allergy is evident and potentially of great pathogenic relevance. Stress was recently shown to activate elements of this component and is vividly discussed as a cause of exacerbation. However, to date, scientific proof of stress-induced neuronal plasticity and neuro-immune interaction in atopy or allergy remains lacking. Here we show early evidence that exposure to sound stress and atopic dermatitis-like allergic dermatitis (AD) equipotently raise the number of cutaneous nerve fibers containing the prototypic stress neuropeptide substance P (SP) in mice. Stress increases AD readout parameters by at least 30% (eosinophil infiltration, vascular cell adhesion molecule-positive blood vessels, epidermal thickness). This dramatic pathologic exacerbation is associated with increased neurogenic inflammation (degranulated mast cells; interstitial neuropeptidergic dense core granules, mast cell apoptosis, endothelial gaping). Key features of AD exacerbation could not be induced in mice lacking the neurokinin-1 SP receptor (NK1). Interestingly, stress had no significant additional effect on CD4+ cell number, but shifted the cytokine profile toward TH2 in skin. Thus, we conclude that stress primarily exacerbates AD via SP-dependent cutaneous neurogenic inflammation and subsequent local cytokine shifting and should be considered as a therapeutic target, while it offers a convincing pathogenic explanation to affected patients and their frustrated physicians alike.

[Influence of anxiety in diverse cutaneous diseases]

INTRODUCTION

The objective of the current study is to determine the levels of anxiety in patients with dermatological diseases compared to healthy subjects and the degree of anxiety in the different cutaneous diseases.

MATERIAL AND METHODS

It is a descriptive study of a case series where 152 patients are selected, 20 of whom are healthy controls and the other 132 are patients that attend a Dermatology clinic. The patients are divided into 5 groups based on the cutaneous disorder for which they attend the clinic: chronic urticaria, acute urticaria, plaque psoriasis, atopic dermatitis, and a miscellaneous group (includes several diagnoses such as seborrheic keratosis, follow-up of multiple nevi, carcinomas...) where, a priori, anxiety does not influence these disorders. Spielberger State-Trait Anxiety Inventory (STAI) is administered to the participating subjects and the differences in State Anxiety Inventory (SAI) and Trait Anxiety Inventory (TAI) for the different groups are analyzed. Patients were asked to report any stressful event in the six months prior to the appearance of the disease that might have been a trigger, and they were also asked about history of psychiatric disorders or atopy.

RESULTS

We observed significant differences in the means obtained in SAI and TAI in healthy subjects compared to patients. We obtained higher mean scores in SAI in patients diagnosed of atopic dermatitis, that were significant when compared with patients with chronic urticaria or other diseases. Forty-eight percent of patients with psoriasis and 38.89 % of patients with atopic dermatitis report a stressful event in the past six months compared to 11.54% of patients from the group with miscellaneous diseases and, additionally, patients with psoriasis and atopic dermatitis have the highest mean scores in the anxiety tests. Twenty-one percent of the 132 patients with cutaneous diseases report a history of psychiatric disorders, showing statistically significant higher mean scores in STAI.

CONCLUSION

The findings show the comorbidity of psychiatric disorders in patients with chronic cutaneous diseases and the high levels of state and trait anxiety, mainly in patients with psoriasis and atopic dermatitis.

Expression pattern of somatostatin receptor subtypes 1-5 in human skin: an immunohistochemical study of healthy subjects and patients with psoriasis or atopic dermatitis

In psoriasis and atopic dermatitis, the inflammatory events have neurogenic components and the neuropeptides modify the functions of immuno-active cells in the skin. Somatostatin is a neuropeptide with several neuroendocrine and immunomodulating properties and mediates its actions by five distinct subtypes of G-protein-coupled receptors (SSTR1-5). This study describes the distribution of SSTR1-5, analysed with immunohistochemistry, in psoriasis, atopic dermatitis and controls. Normal human skin and lesional skin from patients with psoriasis or atopic dermatitis showed many similarities, but also some differences, as regards SSTR expression. SSTR1-3 were strongly expressed in the epidermis of healthy skin, and in the skin of patients with psoriasis or atopic dermatitis. It is noteworthy that SSTR4 and 5 were strongly expressed in the epidermis of psoriasis patients, but weakly expressed in the epidermis of those with atopic dermatitis and normal skin. The intensity of the staining also varied considerably between the different layers of the epidermis, especially in psoriasis patients. In all cases, the dendritic cells, found mostly in the papillary and upper reticular dermis, showed a strong expression of SSTR1-4, but a weak expression of SSTR5. SSTR1-5 were strongly expressed in the sweat glands in all skin biopsies. Hair follicles and sebaceous glands expressed all five subtypes. Striated muscle fibres showed an intense positive expression of SSTR1-4, but a weak or negative expression of SSTR5. The wide distribution and expression pattern of all five SSTRs in human skin suggest that somatostatin is involved in the interactions between the nervous system and the skin.

A new wrinkle: skin manifestations of aging may relate to autonomic dysfunction

Various mechanisms have been argued for skin wrinkling, one of the hallmarks of aging. We hypothesize that chronic sympathetic bias is a previously unrecognized mechanism for wrinkling. In the acute setting of water immersion, reversible skin wrinkling is a well-known reflex mediated by the autonomic nervous system. We postulate that skin wrinkling results as a local maladaptive manifestation of a global chronic sympathetic bias that emerges during aging. The persistence of such changes may induce additional compensatory remodeling to cause permanent alteration of the skin. Sympatholytic agents may prove beneficial for arresting or ameliorating the development of wrinkles. Conditions that amplify sympathetic bias such as stress, smoking, amphetamine abuse, HIV, heart failure, and transplantation may accelerate wrinkling. Other common diseases of the skin may also arise as particular manifestations of aberrant autonomic activity through induction of vascular and immune dysfunctions. The temporal and spatial distribution of these dermatologic conditions may reflect variation of autonomic balance, which also regulates T helper immune balance. For all of these dermatologic conditions, local and systemic administration of drugs and medical devices that pharmacologically or electrically modulate autonomic nervous system activity may yield benefits as well.