Stressful life events, social support, attachment security and alexithymia in vitiligo. A case-control study

Anxiety-depression: a pivotal mental factor for accelerating disease progression and reducing curative effect in vitiligo patients

Objective

To clarify the causal relationship between anxiety-depression and the progression and outcomes of vitiligo, providing a basis for enhancing psychological interventions in the treatment of vitiligo.

Methods

A two-sample Mendelian randomization analysis was used to validate the causal relationship between anxiety, depression, and vitiligo. The Hospital Anxiety and Depression Scale (HADS) assessed the psychiatric condition of vitiligo patients. Fisher's chi-square tests and rank sum tests analyzed the differences in clinical characteristics among vitiligo patients with different HADS scores. Regression analysis assessed the correlation between anxiety-depression and disease progression and treatment outcomes.

Results

Mendelian randomization analysis showed that depression significantly increases the risk of vitiligo (OR = 4.46, 95% CI: 1.16-17.18, p = 0.03). According to the HADS scores, clinical characteristics differed significantly among the groups (p < 0.05). Univariate regression analysis demonstrated that both HADS (B = -1.168, p < 0.001, 95% CI: -1.532 to -0.804) and VIDA (B = -2.157, p < 0.001, 95% CI: -3.464 to -0.887) were significantly negative associated factors for disease outcomes. However, HADS (B = -1.006, p < 0.001, 95% CI: -1.475 to -0.657) emerged as the only factor influencing therapeutic efficacy in multivariate regression analysis. A restricted cubic spline graph illustrates a U-shaped relationship between HADS and clinical efficacy, with the most significant impact on therapeutic efficacy occurring when HADS equals 15.

Conclusion

Anxiety-depression exhibit a bidirectional positive causal relationship with vitiligo. Moderate to severe anxiety-depression significantly influences the clinical efficacy of vitiligo treatment.

The brain-skin axis in vitiligo

Vitiligo is an acquired autoimmune skin disease characterized by patchy depigmentation of the skin, often accompanied by white hair. The aetiology of vitiligo is complex and difficult to cure, and its disfiguring appearance significantly impacts patients' mental and physical health. Psychological stress is a major factor in inducing and exacerbating vitiligo, as well as affecting its treatment efficacy, though the specific mechanisms remain unclear. Increasing research on the brain-skin axis in skin immunity suggests that psychological stress can influence local skin immunity through this axis, which may play a crucial role in the pathogenesis of vitiligo. This review focuses on the role of brain-skin axis in the pathogenesis of vitiligo, and explores the possible mechanism of brain-skin axis mediating the pathogenesis of vitiligo from the aspects of sympathetic nervous system, hypothalamic-pituitary-adrenal (HPA) axis and hormones and neuropeptides, aiming to provide the necessary theoretical basis for psychological intervention in the prevention and treatment of vitiligo.

Possible Implications of Managing Alexithymia on Quality of Life in Parkinson's Disease: A Systematic Review

Alexithymia, characterized by difficulty in recognizing and verbalizing emotions, is reported to be more prevalent in subjects with Parkinson's disease (PD) than in the general population. Although it is one of the nonmotor symptoms of PD, alexithymia is often overlooked in clinical practice. The aim of this systematic review is to investigate the prevalence of alexithymia in PD, assess its impact on quality of life, and explore the rehabilitation approaches for alexithymia. Research articles, selected from PubMed, Scopus, and Web of Science, were limited to those published in English from 2013 to 2023. The search terms combined were "Alexithymia," "Parkinson's disease,", and "Quality of life." Current literature review indicates that alexithymia is commonly assessed using the Toronto Alexithymia Scale (TAS-20), and it is associated with deficits in visuospatial and executive functions. Presently, rehabilitation interventions for alexithymia are scarce, and their effectiveness remains controversial. Future research should focus on developing comprehensive assessments and rehabilitation strategies for emotional processing, considering its significant impact on the quality of life of both patients and caregivers.

Psychosocial implications of rare genetic skin diseases affecting appearance on daily life experiences, emotional state, self-perception and quality of life in adults: a systematic review

BACKGROUND

Since the beginning of human genetic research, there are very few publications sharing insights of the negative impact of rare genetic skin diseases (RGSD) on patients' experiences. This systematic review assessed the psychosocial implications of these conditions in terms of daily life experiences, emotional state, self-perception, and Quality of Life (QoL).

METHODOLOGY

A systematic review was carried out on albinism, neurofibromatosis type 1 (NF1), birthmarks and inherited ichthyosis. The PubMed, Scopus, PsycArticle, PsychInfo, Psychology and Behavioral Sciences Collection, and SOCindex databases were queried. Inclusion criteria were adult patients with one of these RGSDs. Simple descriptive statistics and qualitative content analysis were conducted to summarize the main results reported by the authors.

RESULTS

Of the 9987 articles retrieved, 48 articles were included: albinism (16), NF1 (16), inherited ichthyosis (10), birthmarks (6). The majority of the studies on albinism were conducted in Africa. Twenty-seven studies quantitatively assessed diverse psychological parameters: 13 showed a significant impact of the disease on QoL, five on emotional state, two on self-representation and two others on psychiatric comorbidities. Disease severity and visibility were good predictors of QoL (except for albinism). Body image and appearance concerns were also associated with QoL and emotional state. The 19 qualitative studies highlighted recurring themes across each of these diseases: discrimination and stigma during childhood and adolescence, discomfort in social interactions, guilt of transmission, the importance of social support from family and friends, altered daily life functioning, altered romantic and sex life, limited academic and professional aspirations, lack of interest and support from the medical field, and the unpredictability of the evolution of the disease. The only two mixed-method studies in this review were unable to contribute to any inferential analyses but could corroborate some of the qualitative findings.

CONCLUSION

These results showed that RGSDs have a significant impact on different aspects of patients' lives. This review has demonstrated that there is a real need for support systems for patients with these diseases. Such systems should be developed to provide them with necessary information and to guide them through an appropriate care pathway.

The association between social support and depression among patients with vitiligo in China

Vitiligo is a common depigmenting skin disease with profound psychosocial impacts. Depression is one of the most common mental distress. Social support has a significant impact on the psychological status of patients. The aim of this study is to investigate the depression and social support status of patients with vitiligo in China, and further explore the correlation between social support and depression. The outpatients with vitiligo were investigated face to face with SDS (Self-rating depression scale) and SSRS (Social support rate scale). The mean SDS score of the patients was 44.05 ± 6.76, which was significantly higher than Chinese norms (p = 0.000). Female patients, unmarried, disease at rapid progressive stage and skin lesions at the exposed site had higher SDS scores (all p < 0.05). The scores of total social support, subjective support, objective support and support availability were lower than Chinese norms (all p < 0.01), and all were negatively correlated with SDS scores (all p < 0.001). In conclusion, low social support is one of the risk factors for depression in patients with vitiligo in China. More support and acceptance should be given to the patients.

Evaluation of the Behavioral and Psychological Symptoms in Patients with Vitiligo in China

Background

Vitiligo is a common, acquired depigmenting disorder. The pathogenesis is not clear, neuropsychological factors may be involved. Vitiligo will affect the individual’s physical and psychological health, leading to different levels of psychological behavior problems. However, there are few research on psychological symptoms in patients with vitiligo in China.

Methods

Adult patients with vitiligo were selected in convenient sampling method from March 2019 to November 2019 from the dermatology clinic. They were evaluated by the DLQI (Dermatology Life Quality Index), SCL-90 (Symptom Checklist-90), SADS (Social Avoidance and Distress Scale) and MCMQ (Medical Coping Modes Questionnaire).

Results

The DLQI score was 7.56 ± 6.11, which was in the third level. The SCL-90 score of patients with vitiligo was 136.44 ± 39.19, significantly higher than the Chinese norms (P < 0.05), and it mainly manifested as interpersonal sensitivity, depression, anxiety and phobia, which may be affected by the patient’s gender, marital status, severity of disease, stage and location of skin lesions. The total score of SADS in patients was 10.30 ± 6.38. The total score and scores in all dimensions of SADS were significantly higher than the Chinese norms (all P < 0.05), which were related with the patient’s gender, educational attainment, severity, type and stage of skin lesions. For MCMQ, the facing score was significantly lower than the Chinese norms (P < 0.05), and the avoiding and yielding scores were significantly higher than the Chinese norms (all P < 0.05).

Conclusion

In China, vitiligo affects the patient’s quality of life to varying degrees, resulting in a series of psychological and behavioral problems. We should actively concern and improve the psychological health status and behavior of patients, and multidisciplinary treatment strategies and education about vitiligo should be given to the patients.

Alexithymia in Adolescents with Acne: Association with Quality of Life Impairment and Stigmatization

Alexithymia seems to be more common among patients with skin diseases. However, studies on acne patients are very limited. We conducted this study to evaluate alexithymia in adolescents with acne. In our cross-sectional study, 730 high school students (mean age: 17.05 ± 1.18 years) were recruited. The Toronto Alexithymia Scale (TAS-20) was used to measure alexithymia, the Dermatology Life Quality Index (DLQI) was employed to study quality of life (QoL), and the 6-item Stigmatization Scale (6ISS) was used to evaluate the level of stigmatization in acne subjects. Alexithymia was found in 31% of adolescents, with similar prevalence among those with and without acne (31.3% and 30.1%, respectively). The mean scoring on the TAS-20 in patients with acne (53.1 ± 12.8 points) was not significantly different from that of the non-acne group (53.5 ± 11.9 points). However, significant correlations between TAS-20 scores and QoL assessments (r = 0.332, p < 0.001) as well as stigmatization level (r = 0.284, p < 0.001) were found. These correlations were also significant for the domains of alexithymia described as difficulty in identifying feelings (DIF) and difficulty in describing feelings (DDF), but not for externally oriented thinking (EOT). The findings clearly showed that acne does not predispose to alexithymia; however, alexithymia in acne subjects is related to impaired QoL and stigmatization.

Psychosocial Effects of Vitiligo: A Systematic Literature Review

Background

Patients with vitiligo experience reduced quality of life.

Objective

To comprehensively describe the available evidence for psychosocial burden in vitiligo.

Methods

A systematic review of observational studies and clinical trials identified using PubMed, EMBASE, Scopus, and the Cochrane databases was performed through 1 March, 2021, to assess psychosocial comorbidities in vitiligo. Two independent reviewers performed an assessment of articles and extracted data for qualitative synthesis.

Results

Included studies (N = 168) were published between 1979 and 1 March, 2021; 72.6% were published since 2010. Disorders including or related to depression (41 studies, 0.1–62.3%) and anxiety (20 studies, 1.9–67.9%) were the most commonly reported. The most prevalent psychosocial comorbidities were feelings of stigmatization (eight studies, 17.3–100%), adjustment disorders (12 studies, 4–93.9%), sleep disturbance (seven studies, 4.6–89.0%), relationship difficulties including sexual dysfunction (ten studies, 2.0–81.8%), and avoidance or restriction behavior (12.5–76%). The prevalence of most psychosocial comorbidities was significantly higher vs healthy individuals. Factors associated with a significantly higher burden included female sex, visible or genital lesions, age < 30 years (particularly adolescents), and greater body surface area involvement, among others. The most commonly reported patient coping strategy was lesion concealment.

Limitations

Available studies were heterogeneous and often had limited details; additionally, publication bias is possible.

Conclusions

The results of this systematic review show that vitiligo greatly affects psychosocial well-being. The extent of psychosocial comorbidities supports the use of multidisciplinary treatment strategies and education to address the vitiligo-associated burden of disease.

Protocol Registration

PROSPERO (CRD42020162223).

Graphic Abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s40257-021-00631-6.

Alexithymia and self-harm: A review of nonsuicidal self-injury, suicidal ideation, and suicide attempts

INTRODUCTION

Suicide attempts are a significant global public health concern. Research into non-traditional factors, such as the presence of alexithymia, may shed light on the prediction of suicidal behaviours, which can aid intervention and prevention strategies. To ascertain whether alexithymia is a unique risk factor for suicide attempts, this article reviews the evidence on alexithymia related to suicidal ideation, attempts, and non-suicidal self-injury (NSSI).

METHODS

A literature search was conducted for original articles examining the general and psychiatric populations.

RESULTS

There is consistent evidence linking alexithymia with suicidal ideation and NSSI, but inconsistent evidence linking it to suicide attempts.

CONCLUSION

The relationship between alexithymia and suicidality seems to differ based on whether the research focuses on suicidal ideation, suicide attempts, or NSSI. The relationship between alexithymia and suicidality can be understood within the context of multiple code theory and childhood trauma. Future research should explore the whether alexithymia can reliably distinguish between those with a single attempt and those with multiple suicide attempts as well as alexithymia levels pre- and post-intervention with suicide-related behavior as outcomes in treatment studies.

Psychological Distress, Alexithymia and Alcohol Misuse in Patients with Psoriasis: A Cross-Sectional Study

This study investigates (a) the prevalence of psychological distress, alexithymia and alcohol misuse in psoriasis patients; and (b) the relationship between psoriasis severity, alexithymia, alcohol and psychological distress in patients with psoriasis. A cross-sectional study was conducted. Outpatients (n = 184) with moderate to severe psoriasis completed a psychological screening battery. Measures included the Hospital Anxiety and Depression Scale, the Penn State Worry Questionnaire, the twenty-item Toronto Alexithymia Scale, the Dermatology Life Quality Index, the Psoriasis Area and Severity Index, the Self-Administered Psoriasis Area and Severity Index, and the Alcohol Use Disorders Identification Test. Demographic, clinical details and information on knowledge of psychosocial issues, alcohol and confidence on coping with distress and talking to others about psoriasis was also gathered. Alexithymia was associated with anxiety, depression and worry; subjective psoriasis severity was associated with worry. Alcohol misuse was related to anxiety and worry, but not to depression. Appropriate identification and treatment of alcohol difficulties and psychological distress of patients with psoriasis is needed.

Skin - a vast organ with immunological function (Review)

The skin is an organ with multiple functions, where important inflammatory and immunological processes take place. The integrity of the skin barrier is necessary for it to fulfill its roles. An intact skin barrier requires a physiological keratinization process, but also a normal cutaneous microbial flora. Any change in the proliferation and differentiation of keratinocytes entails the disruption of the skin barrier and the triggering of inflammatory and immunological processes at this level, in response to the aggression of external pathogens. Also, there are several specialised immune cells in the skin (Langerhans cells, T regulator cells, T helper cells), that maintain a balance between pro-inflammatory and anti-inflammatory processes at this level. Disturbing the immune homeostasis causes inflammation and allergic skin reaction. Psoriasis and atopic dermatitis are two inflammatory diseases of the skin, characterized by perturbation of the mechanisms of skin barrier formation. The immune system of the skin is also involved in the pathophysiology of vitiligo and pemphigus. The aim of this review is to offer a brief presentation of the inflammatory and immunological processes that occur in the skin.

Association of serum cortisol and dehydroepiandrosterone sulfate (DHEAS) levels with psychological stress in patients with vitiligo

Background/aim

Vitiligo is a depigmentation disorder that leads to serious psychological burden in patients, who are frequently reported to have depression and anxiety. The aim of this study was to investigate the association between stress-related hormone levels and psychological stress in vitiligo.

Materials and methods

In this study 46 vitiligo patients and 46 controls were enrolled; their cortisol, dehydroepiandrosterone sulfate (DHEAS), and cortisol/DHEAS levels were measured. Psychological burden was assessed by the Beck Depression Inventory and Perceived Stress Scale.

Results

Patients and controls did not differ in terms of cortisol, DHEAS, or cortisol/DHEAS. Patients had higher perceived stress than controls but did not differ in terms of depression scores. Correlation analyses revealed that cortisol/DHEAS correlated positively with perceived stress (P = 0.009, r = 0.272). The correlation between cortisol/DHEAS and perceived stress was stronger in the patient group (P = 0.013, r = 0.363) and close to zero among controls. In regression analyses, lower depression and higher perceived stress were shown to predict cortisol/DHEAS values.

Conclusion

Vitiligo patients significantly differed from the healthy population in terms of hormones and psychological distress. There was also an association between perceived stress and cortisol/DHEAS ratio in vitiligo. Abnormality of hormonal response to distress lowers DHEAS, which is known for its antioxidant properties, a possible mechanism for vitiligo development. Another important finding is the significance of using the composite variable cortisol/DHEAS, which seems to be more sensitive to distress than each of its components. We suggest its use in future studies on psychological distress–hormone relationships.

Gender Differences in Depression, Coping, Stigma, and Quality of Life in Patients of Vitiligo

Though vitiligo is one of the psychodermatological disorders which do not cause direct physical impairment, it is cosmetically disfiguring leading to serious psychological problems in daily life. We undertook this research to study patients of vitiligo the prevalence of depression, coping, stigma, and quality of life and comparison of the same in both genders. Patients diagnosed clinically as having vitiligo by consultant dermatologist were enrolled after informed consent and ethics approval. 156 patients were screened, of which 100 satisfying criteria were taken up for the study. A semistructured proforma was designed to collect the necessary information with administration of Beck's depression inventory, participation scale, dermatology life quality index, and adjustment to chronic skin diseases questionnaire. Depression prevalence was 63.64% in females and 42.86% in males (p<0.0457); the total mean BDI scores were significant with females having higher scores than males (p<0.0083). No significant differences were seen on participation scale though 52% females felt stigmatized as compared to 45% males (p <0.5779). While almost 97% of our patients had impaired quality of life there was no significant difference in both genders on the total score (p<0.3547). Females had significantly higher faulty coping style than males with significant differences on all domains and total scores (p< 0.0094). There was a strong association of depression with faulty coping and stigma (p< 0.0001) in both genders. Also association of stigma with quality of life showed highly significant findings in both genders (p< 0.0001) on all the domains of DLQI. This study helps in early identification of psychological problems in vitiligo patients and planning their future course of management, hence improving the prognosis and quality of life.

Therapeutic interventions to lessen the psychosocial effect of vitiligo in children: A review

Vitiligo commonly affects children, with half of affected individuals experiencing disease onset before the age of 20. Because childhood is a time of advancement in social and psychological development, understanding the extent of the effect of the disease and means of alleviation is crucial. Vitiligo has been shown to decrease children's quality of life, with greater distress in children with highly visible lesions and darker skin tones. This article reviews the literature regarding interventions that have been analyzed in children. Studies evaluating the effect of camouflage, cognitive behavioral therapy, psychological self-help tools, and support groups on the psychosocial aspects of vitiligo were included. The review highlights the ongoing need for studies to better understand the modalities described in this article, as well as others, such as skin dyes, bleaching creams, medical tattooing; week-long camps that cater to children with chronic skin disease; and biofeedback, that might have a role in preventing the psychosocial sequelae of childhood vitiligo.

The convergence theory for vitiligo: A reappraisal

Vitiligo is characterized by progressive loss of skin pigmentation. The search for aetiologic factors has led to the biochemical, the neurologic and the autoimmune theory. The convergence theory was then proposed several years ago to incorporate existing theories of vitiligo development into a single overview of vitiligo aetiology. The viewpoint that vitiligo is not caused only by predisposing mutations, or only by melanocytes responding to chemical/radiation exposure, or only by hyperreactive T cells, but rather results from a combination of aetiologic factors that impact melanocyte viability, has certainly stood the test of time. New findings have since informed the description of progressive depigmentation. Understanding the relative importance of such aetiologic factors combined with a careful selection of the most targetable pathways will continue to drive the next phase in vitiligo research: the development of effective therapeutics. In that arena, it is likewise important to acknowledge that pathways affected in some patients may not be altered in others. Taken together, the convergence theory continues to provide a comprehensive viewpoint of vitiligo aetiology. The theory serves to intertwine aetiologic pathways and will help to define pathways amenable to disease intervention in individual patients.

Stress and skin disease quality of life: the moderating role of anxiety sensitivity social concerns

BACKGROUND

Stress is an important factor in the onset, exacerbation and reoccurrence of many skin diseases. Little is known about psychological risk factors that affect the association between stress and dermatological conditions. One relevant factor that may modulate this link is anxiety sensitivity (AS) social concerns - the propensity to respond fearfully to anxiety-related sensations (e.g. sweating, flushing) owing to perceived social consequences (e.g. rejection or humiliation).

OBJECTIVES

To gain insight into psychological factors affecting skin disease, we examined the moderating role of AS social concerns in the relationship between stress and skin disease quality of life (QoL).

METHODS

Participants [n = 237 (161 female), mean ± SD age 34·18 ± 9·57 years] with active skin disease symptoms were recruited online and completed questionnaires assessing stress, AS social concerns, skin disease QoL and global skin disease symptom severity.

RESULTS

AS social concerns moderated the association between stress and skin-related emotional and social functioning in adults with skin disease. Stress was a significant predictor of the impairment associated with skin disease.

CONCLUSIONS

Stress was linked to skin disease-related emotional and functional impairment associated with skin disease among individuals with high AS social concerns. These results highlight the potential for AS reduction interventions to break the vicious cycle of stress and skin disease symptoms and to improve psychosocial well-being in dermatology patients.

Alexithymia in different dermatologic patients

Alexithymia is a personality trait characterized by difficulties in differentiating and describing feelings. Research indicates that alexithymia can be considered as a possible risk factor for a variety of medical conditions. The purpose of our study was to compare and assess the prevalence of alexithymia in patients with psoriasis, alopecia areata, vitiligo and acne vulgaris. 120 consecutive subjects referred to dermatologic clinic with psoriasis, alopecia areata, vitiligo and acne vulgaris and 30 subjects selected from hospital staff and relatives of patients were enrolled in patient and control groups of our study respectively. Toronto Alexithymia Scale (TAS-20) was used to assess the prevalence of alexithymia. Statistical analysis showed significant differences between the vitiligo, alopecia areata, psoriasis patients and the control group in terms of alexithymia score (p≤0.05), but did not find any significant difference between acne patients and control group (p=0.06). This study has demonstrated high score of alexithymia in patients with psoriasis, alopecia areata and vitiligo compared with control group; however, such association was not found in individuals with acne vulgaris. Hence it is proposed that the evaluation and management of alexithymia would better the treatment of skin disorders and improve the quality of life in patients.

Psychosomatic aspects of vitiligo

Vitiligo is a chronic common skin disease. The asymptomatic hypopigmented cutaneous lesions are considered by many health care professionals as a cosmetic problem only; however, vitiligo can have a major psychosocial impact on patients' lives. We review some of the factors responsible for this impact, such as the general public's wrong perception of the disease, feelings and emotional responses from patients, how stressful events can act as triggers of the disease, stigmatization experiences suffered by the patients, the prevalence of psychiatric morbidity, the effects on relationships and sex life, how quality of life in adults and children is impaired, and how treatment can improve it.

Focus on Vitiligo: A Generalized Skin Disorder

Vitiligo is an acquired pigmentation disorder due to a disappearance of functioning melanocytes from the epidermis and clinically characterized by achromic patches, often spreading over time. It is still not fully understood how melanocytes disappear in vivo, inducing these peculiar lesions. There are three major hypotheses for the pathogenesis of the disease: the autoimmune hypothesis considers that the disappearance of melanocytes is due to an autoimmune effector mechanism, the neural hypothesis suggests that an accumulation of neurochemical substances is able to damage epidermal melanocytes, and the metabolic hypothesis indicates that an increased sensitivity of melanocytes to oxidative stress is the crucial factor of the disease. Besides these well accepted hypotheses there are also some new interpretations based on a defective adhesion of melanocytic cells, an imbalance in the epidermal production of cytokines and an altered expression of melanocyte receptors. All these theories seem to be based on convincing evidence, indicating that they may contribute in variable proportions to the disease. There is also reasonable evidence at present that vitiligo potentially involves the whole integument, suggesting that it is a generalized skin disorder probably including different cell types during the active phase of the disease. It appears that the different theories may integrate with each other, supporting the concept that in vitiligo there is a final common step, i.e. a loss of pigment in the epidermis as well as different, possibly interacting, pathways leading up to this conclusive result.

Distinct temperament and character profiles in first onset vitiligo but not in alopecia areata

Alopecia areata (AA) and vitiligo (V) are diseases that are correlated with psychiatric disorders before, during and after diagnosis. The Temperament and Character Inventory (TCI) is a well-established approach for investigating personality traits in various psychosomatic diseases. The aim of this study is to compare and investigate the differences in the TCI between patients with first onset AA, patients with V and healthy controls (HC). Participants in the study included 42 patients with first onset AA, 50 adult patients with V and 60 HC who had no history or diagnoses of psychiatric or dermatological disorders. All participants were assessed with the TCI and the Dermatology Life Quality Index (DLQI). Among the temperament traits, the extravagance, disorderliness and total novelty-seeking scores were lower, and the worry and pessimism scores were higher in patients with V compared with patients with AA and the HC. The mean score of the enlightened second nature and the total self-directedness score of the character traits were higher in patients with V compared with patients with AA and the HC group. In the AA group, there was a negative correlation only between the reward dependence total score and the DLQI score. This study suggests that patients with first onset V have a distinct temperament, such as being unenthusiastic and unemotional, and character profiles, such as worry and pessimism, independent of their psychiatric comorbidities, and patients with AA do not have a different personality from the non-affected population.

Radiation induced depigmentation disorder in two patients with breast cancer: Exploring a rare accompaniment

Radiation induced depigmentation disorder is a rare accompaniment. We herein report two patients of bilateral breast cancer developing depigmentation disorder, initially confined to the radiation portal with subsequent generalization within few months of completion of whole breast radiotherapy. Both these patients had no prior history of vitiligo or other autoimmune disorder. This brief report highlights the importance of awareness of this association in appropriate decision making in susceptible patients thereby preventing this morbidity and its psychological ramifications.

Psychiatric morbidity and quality of life in vitiligo patients

BACKGROUND

Vitiligo has underlying mental illness but mostly not diagnosed and never used psychiatric medication. Hence, the problem persists affecting mostly the individual's quality of life.

AIM

Assessing the quality of life, level of depression, and self-esteem of patients with vitiligo and give psychiatric medication for underlying mental illness.

MATERIALS AND METHODS

The study conducted at Owaisi Hospital Research Centre, Hyderabad. The patients registered for dermatologist consultation were also registered for consultation with psychiatrist to rule out any mental illness after detailed evaluation using standardized scales.

RESULTS

Patients suffering with vitiligo had depression and low self-esteem; their quality of life was disturbed.

CONCLUSION

The findings provide the role of Mental Health Professionals involved in the field of dermatology for the patients suffering with vitiligo.

Preferential secretion of inducible HSP70 by vitiligo melanocytes under stress

Inducible HSP70 (HSP70i) chaperones peptides from stressed cells, protecting them from apoptosis. Upon extracellular release, HSP70i serves an adjuvant function, enhancing immune responses to bound peptides. We questioned whether HSP70i differentially protects control and vitiligo melanocytes from stress and subsequent immune responses. We compared expression of HSP70i in skin samples, evaluated the viability of primary vitiligo and control melanocytes exposed to bleaching phenols, and measured secreted HSP70i. We determined whether HSP70i traffics to melanosomes to contact immunogenic proteins by cell fractionation, western blotting, electron microscopy, and confocal microscopy. Viability of vitiligo and control melanocytes was equally affected under stress. However, vitiligo melanocytes secreted increased amounts of HSP70i in response to MBEH, corroborating with aberrant HSP70i expression in patient skin. Intracellular HSP70i colocalized with melanosomes, and more so in response to MBEH in vitiligo melanocytes. Thus, whereas either agent is cytotoxic to melanocytes, MBEH preferentially induces immune responses to melanocytes.

Reduced serum brain-derived neurotrophic factor in patients with first onset vitiligo

PURPOSE

Vitiligo is an acquired pigmentary skin disease that can cause serious cosmetic problems. There have been numerous and well established studies that have demonstrated the comorbidity of various psychiatric disorders in patients with vitiligo. However, to our knowledge, there have been no studies investigating whether a psychiatric biomarker, such as brain-derived neurotrophic factor (BDNF), is associated with vitiligo.

PATIENTS AND METHODS

This study was conducted in Namık Kemal University Medical Faculty, Departments of Dermatology and Psychiatry between January 2013 and September 2014. After meeting inclusion and exclusion criteria, serum BDNF levels were assayed in 57 patients with first onset vitiligo and no known current or past psychiatric disorder and compared with BDNF levels in 58 age and sex matched healthy subjects.

RESULTS

The age and female/male ratios were similar between groups. The mean values of serum BDNF were 1.57±0.97 ng/dL and 2.37±1.73 ng/dL in the vitiligo group and in the healthy control group, respectively. The mean BDNF level was significantly higher in the healthy control group compared with the vitiligo group (t=2.76, P=0.007).

CONCLUSION

This is the first study to compare serum BDNF levels between patients with vitiligo and healthy subjects. The reduced level of serum BDNF in patients with vitiligo may be directly related to the etiology of vitiligo or associated with the high percentage of psychiatric disorders in that patient population. Further studies are needed to support our preliminary results.

Ayurvedic management of adverse drug reactions with Shvitrahara Varti

Adverse drug reactions (ADR) are an expression that describes harm associated with the use of medications at therapeutic dose. Traditional medicines also can develop ADRs due to their improper use. Shvitrahara Varti, one of such medicines holds Bakuchi as a component and is to be used judiciously. Furanocoumarins like psoralen present in Bakuchi makes skin hypersensitive and causes phytophotodermatitis in few cases. Hence, one should be careful while using medicines that contain Bakuchi. One such case is observed, where extensive reactions with application of Shvitrahara Varti were noticed and managed with Ayurvedic treatment.

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.

Psychiatric comorbidities and alexithymia in patients with seborrheic dermatitis: a questionnaire study in Turkey

OBJECTIVE

The aim of the study was to determine the levels of anxiety, depression, and obsessive-compulsive symptoms in patients with seborrheic dermatitis (SD) compared with healthy subjects. Additionally, we aimed to investigate the presence of alexithymia among patients and its association with these psychiatric comorbidities.

METHODS

A total of 117 consecutive adult patients (66 male, 51 female) with SD and 95 age- and gender-matched healthy controls selected from the community (46 male, 49 female) were enrolled in the study. The demographic characteristics of the patients were recorded. The clinical severity of the disease was assessed according to the Seborrheic Dermatitis Area and Severity Index (SDASI) scoring system. Both patients and controls were evaluated by the validated Turkish versions of the Hospital Anxiety and Depression Scale (HADS), Maudsley Obsessive Compulsive Inventory (MOCI), and Toronto Alexithymia Scale (TAS-26).

RESULTS

There were no statistically significant differences between the patient and control groups regarding the mean scores of depressive or obsessive-compulsive symptoms or alexithymia (all p > 0.05). However, anxiety scores in patients with SD were higher than in controls (p = 0.001). No significant relationship was present between anxiety and disease severity nor disease duration (p > 0.05). Thirty-eight patients with high anxiety scores were found to be more alexithymic (p = 0.000).

CONCLUSION

SD is one of the inflammatory skin disorders that is known to be triggered or aggravated by stress. However, little scientific evidence exists to confirm this view. In addition, very limited data are available about the presence of the personality profiles leading to emotional dysregulation such as alexithymia and concurrent psychiatric disorders in patients with SD. Our study showed that anxiety levels were significantly higher in patients with SD compared with healthy controls but there was no significant association with alexithymia, depression, or obsessive-compulsive symptom levels. Dermatologists should be particularly vigilant to the possibility of concurrent psychiatric morbidity in patients with SD in order to improve patients' well-being.

Psychosomatic factors in pruritus

Pruritus and psyche are intricately and reciprocally related, with psychophysiological evidence and psychopathological explanations helping us to understand their complex association. Their interaction may be conceptualized and classified into 3 groups: pruritic diseases with psychiatric sequelae, pruritic diseases aggravated by psychosocial factors, and psychiatric disorders causing pruritus. Management of chronic pruritus is directed at treating the underlying causes and adopting a multidisciplinary approach to address the dermatologic, somatosensory, cognitive, and emotional aspects. Pharmcotherapeutic agents that are useful for chronic pruritus with comorbid depression and/or anxiety comprise selective serotonin reuptake inhibitors, mirtazapine, tricyclic antidepressants (amitriptyline and doxepin), and anticonvulsants (gabapentin, pregabalin); the role of neurokinin receptor-1 antagonists awaits verification. Antipsychotics are required for treating itch and formication associated with schizophrenia and delusion of parasitosis (including Morgellons disease).

Reliability of self-reported attachment style in patients with severe psychopathology

Little is known about whether severe psychopathology influences the assessment of self-reported attachment style. Fifty-eight randomly selected adult psychiatric inpatients completed the Experiences in Close Relationship questionnaire (ECR; Brennan, Clark, & Shaver, 1998) and were administered the 24-item Brief Psychiatric Rating Scale (BPRS; Ventura et al., 1993) and the Hamilton Depression Rating Scale (HDRS; Hamilton, 1960) at both admission and discharge. The Structured Clinical Interview for DSM-IV (SCID-I; First, Spitzer, Gibbon, & Williams, 1996) was used to establish Axis I diagnoses. The ECR scales showed good internal consistency and absolute stability both in patients with (n = 24) and without (n = 34) a psychotic disorder. Relative stability was only fair among patients with psychotic disorders but good among patients without psychotic disorders. Neither higher BPRS or HDRS scores, nor the presence of a psychotic disorder, significantly reduced the retest reliability of the ECR scales. These findings suggest that self-report measures might provide a reliable assessment of attachment style in patients with severe psychopathology, except for the most severely impaired patients.

Alexithymia and acne vulgaris: a case control study

OBJECTIVE

To assess relationship between alexithymia and acne vulgaris in young people.

METHODS

A hundred and eleven subjects between 15 and 25 years of age referred to out-patient clinic of dermatology with acne and 78 subjects applied to family physician for complaints other than acne were included in patient and control groups of the study, respectively. A questionnaire to determine demographic characteristics, an acne classification to determine severity of acne and Toronto Alexithymic Scale (TAS) to assess alexithymia were used.

RESULTS

The mean scores of TAS were 52.7±10.8 and 51.7±10.7 in patient and control groups, respectively. Alexitymia was determined in 23.4% of the subjects in acne group and in 24.4% of control group. No significant differences were found between groups in terms of alexithymia, intermediate alexitymia and three-factors of TAS.

CONCLUSION

Alexithymia does not appear to be related to acne vulgaris.

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.

Psychological distress and coping strategies in patients attending a dermatology outpatient clinic

BACKGROUND

  Psychological distress is frequent among dermatological patients. The development of a positive attitude toward diagnosis and treatment is thought to be critical for successful coping and mental health outcomes.

OBJECTIVE

  The aim of this study was to assess the coping strategies and the psychological distress, due to anxiety and depression, in an unselected sample of dermatological patients.

METHODS

  Self-administered questionnaires (HADS, COPE) were given to 603 dermatological patients.

RESULTS

  Out of 567 participants, 149 (26.2%) scored positive for Anxiety, and 52 (9.2%) scored positive for Depression. Multivariate analysis, adjusting for gender, age, socio-economic status, and disease, showed that both Anxiety and Depression are associated with a less frequent use of Positive attitude coping.

CONCLUSION

  Our results reinforce the notion that while planning the treatment of dermatological patients, evaluating their mental health might help to provide optimal treatment. Since coping ability was found to be important for mental health status, policy implications could include emphasis on social programs to assist individuals to manage stress, as well as psychological support.

Stress, psychiatric co-morbidity and coping in patients with chronic idiopathic urticaria

This study examined life event stress, perceived stress and psychiatric co-morbidity among patients with Chronic Idiopathic Urticaria (CIU). It also investigated the relationship between coping, stress, the severity of CIU and psychiatric co-morbidity. Total of 100 CIU patients and 60 allergy patients participated in the study. They completed the General Health Questionnaire, the Social Readjustment Rating Scale, the Perceived Stress Scale, and the Ways of Coping Checklist. Compared with allergy patients, CIU patients had worse co-morbidity and higher levels of life event stress and perceived stress. Emotion-focussed coping was associated with the severity of CIU; perceived stress was associated with co-morbidity.

The relationship between posttraumatic stress disorder, psychiatric comorbidity, and personality traits among patients with chronic idiopathic urticaria

BACKGROUND

Several studies have highlighted the link between posttraumatic stress disorder (PTSD) and physical illnesses. No empirical studies, however, have investigated the relationship between PTSD and chronic idiopathic urticaria (CIU). The role of personality traits in this relationship was also unknown.

OBJECTIVES

This study aimed to investigate (1) the extent to which patients with CIU fulfilled the PTSD diagnosis resulting from past traumas and (2) whether they developed psychiatric comorbidity, and (3) the relationship between CIU patients' personality traits, PTSD diagnosis, severity of CIU, and psychiatric comorbidity.

METHODS

One hundred patients with CIU and 60 patients with allergy (control) participated in the study. Patients' CIU severity was assessed. Both groups completed the Posttraumatic Stress Diagnostic Scale, the General Health Questionnaire-28, the Social Readjustment Rating Scale, the Perceived Stress Scale, and the NEO-Five Factor Inventory.

RESULTS

Thirty-four percent of patients with CIU and 18% of allergy patients met the diagnostic criteria for PTSD. Patients with CIU were 1.89 times more likely to have a current diagnosis of PTSD than the control group. Controlling for life event stress and perceived stress, significant differences were found between groups (CIU PTSD, CIU no PTSD, allergy PTSD, allergy no PTSD) in somatic problems, anxiety, and social dysfunction. Controlling for life event stress and perceived stress, regression analyses showed no significant associations between personality traits, PTSD diagnosis, and the severity of CIU. Posttraumatic stress disorder diagnosis and neuroticism were, however, associated with psychiatric comorbidity.

CONCLUSIONS

Patients with CIU have been shown to have concurrent PTSD resulting from past traumas and developed psychiatric comorbidity. Chronic idiopathic urticaria patients' comorbidity was related to the patients' PTSD diagnosis and their neurotic personality trait.

Relationship between attachment style, parental bonding and alexithymia in adults with somatoform disorders

BACKGROUND

This study examines the relationship between parental bonding, adult attachment, and alexithymia in patients with Somatoform Disorders (SFD). There are few empirical studies to support the clinical hypothesis that alexithymia may be due to disturbances in the early parent-child relationship.

SAMPLING AND METHODS

In a cross-sectional study, data from 76 patients with SFD were obtained, consisting of questionnaire measures of alexithymia (TAS scale), attachment style (BFKE), and also the German version of the MOPS (Measure of Parental Style), the FDEB scale for measuring perceived parental attitude.

RESULTS

A higher than average prevalence of insecure attachment (n = 67, 88.2%) was found in our sample with SFD and a T-value of 54.3 (9.5) in the TAS total score, 22% reaching clinically significant alexithymia. Regression analyses demonstrated the relationship between the "ambivalent clinging" and "ambivalent withdrawing" attachment style and more marked alexithymia features. Furthermore, alexithymia was positively predicted by "indifference" in the relationship to the father, BDI, and Global severity index (SCL-90-R).

CONCLUSION

The results of this study support the hypothesis that alexithymia is associated with perceived parental bonding and attachment style.

Alexithymia in multiple sclerosis: relationship with fatigue and depression

OBJECTIVE

The aim of this study was to investigate the prevalence of alexithymia in a sample of patients with multiple sclerosis (MS) and to further evaluate the association between alexithymia and the occurrence of common disabling MS-related symptoms such as fatigue and depression.

METHODS

Fifty-eight relapsing-remitting MS patients treated with interferon (IFN)-beta-1a underwent a complete neurological evaluation, including Expanded Disability Status Scale score assessment. Alexithymia, depressive symptoms and fatigue were assessed using the 20-item Toronto Alexithymia Scale, Beck Depression Inventory and Fatigue Severity Scale.

RESULTS

Prevalence of alexithymia was 13.8%, with 27.6% of patients presenting borderline alexithymia. Sixty-seven per cent of the patients complained of fatigue while 29.3% of them were depressed. Higher levels of fatigue and depression were found in alexithymic patients when compared with non-alexithymic patients. Results from logistic regressions showed that alexithymia significantly contributes to the severity of fatigue and depression.

CONCLUSIONS

Alexithymia was associated with increased severity of fatigue and depression.

Lichen planus patients and stressful events

PURPOSE

To evaluate the possible role of stress before the onset/extension of lichen planus.

PATIENTS AND METHOD

Forty-six outpatients with lichen planus were enrolled. The design was a case-control study (controls had skin diseases with low psychosomatic component). Stressful situations were evaluated using Holmes and Rahe's social readjustment rating scale.

RESULTS

Lichen planus had an incidence of 0.36% among dermatological conditions. In the lichen planus group, there was a female predominance (76%) and a median age around 50 years. More than 67% of cases experienced at least one stressful event, compared with 21% of controls (chi(2) = 17.58, P < 0.001). The odds ratio was 7.44. There was a borderline significant difference in the mean number of stressful events between lichen planus patients and controls (P = 0.06). We divided the situations described by Holmes and Rahe into three categories: family, personal, and job or financial problems. The presence of major life events was significant different in patients and controls (P = 0.005). Family matters were described by 43.6% of lichen planus patients, statistically significant compared with controls (P = 0.002). In almost 25% of cases of lichen planus, 'the stressful event' was represented by the illness or death of someone dear. 'Personal problems' seemed to be important compared with controls (P = 0.04), exams representing 25% of these matters. There was no difference between the patients and controls regarding the importance of job or financial changes.

CONCLUSION

Stressful situations, especially related to family, may have a role in the onset and extension of lichen planus lesions.

Stress in patients with alopecia areata and vitiligo

OBJECTIVE

To study the involvement of stress before the onset/development of alopecia areata and vitiligo.

PATIENTS AND METHOD

Forty-five outpatients with alopecia areata and 32 outpatients with vitiligo were enrolled. The design was a case-control study (controls had skin diseases unrelated to stress). Stressful events were evaluated using Holmes and Rahe's social readjustment rating scale.

RESULTS

Mean age was around 30 years in both conditions. More than 65% of cases (both alopecia areata and vitiligo) experienced stressful events compared to 22% of controls. The odds ratio was 7.75 for alopecia areata and 6.81 for vitiligo. There was a significant difference in the mean number of stressful events between alopecia areata patients and controls (P = 0.005), and also a significant difference in the number of stressful events between men (P = 0.05) and women (P = 0.001) across these two groups. In the vitiligo group there was a significant difference in the mean number of stressful events between patients and controls only in women (P = 0.02). A potential stressful situation occurred more often in both patient groups. Alopecia areata patients described family problems in 45.6% of patients (especially women), which was statistically significant when compared to controls (P = 0.0004). Personal problems were reported by 35.7% of alopecia areata patients (P = 0.04 compared to controls). Vitiligo patients mentioned personal problems in 47% of cases (one-third were related to exams) and 31% of cases were related to job/financial problems. Again, this was statistically significant when compared to controls (P = 0.0002).

CONCLUSIONS

Stress seems to play an important role in the onset and aggravation of both alopecia areata and vitiligo, mostly with one stressful event before disease onset.

Stigmatization experience, coping and sense of coherence in vitiligo patients

OBJECTIVE

This study examines the extent of stigmatization experienced by vitiligo patients considering the visibility of the lesions.

METHODS

363 vitiligo patients were assessed using the Experience with Skin Complaints (QES), Adjustment to Chronic Skin Disorders (ASC), and Sense of Coherence (SOC) questionnaires. Out of the total patients group two representative samples with 52 patients each were identified comparable for age, gender, and the duration of the skin disease, the first with visible and the second with invisible lesions.

RESULTS

Data indicate a significant negative correlation between the QES dimensions, except for 'Composure', and between coping scales with sense of coherence withstanding. The 'visible lesions' group scored higher compared to the 'invisible lesions' group on the two QES scales 'Self-Esteem' and 'Refusal', i.e., patients with visible lesions experienced a higher level of stigmatization.

CONCLUSION

This study provides new information which supports the notion that the stigmatization experience of vitiligo patients is psychologically relevant.

Alexithymia and global psychosocial functioning: a study on patients with skin disease

OBJECTIVE

The relationship between alexithymia and psychosocial functioning has been investigated in a few studies using indirect measures of adaptation. We aimed at directly evaluating the relationship between alexithymia and global psychosocial functioning, as measured by a standardised scale.

METHODS

A large, consecutive sample of dermatological inpatients (N=545) completed the 20-item Toronto Alexithymia Scale and the Skindex-29 and were administered the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Axis I disorders and the Global Assessment of Functioning (GAF) scale.

RESULTS

Multiple regression analysis was used to control for likely determinants of psychosocial functioning such as age, sex, education, burden of skin symptoms, and psychiatric morbidity. The GAF score was associated with psychiatric morbidity (beta=-.63, P<.001), alexithymia (in particular, the difficulty identifying feelings subscale) (beta=-.19, P<.001), and burden of skin symptoms (beta=-.07, P<.05).

CONCLUSION

Given the well-known association between poor psychosocial functioning and several behavioural risk factors for health, our study may provide a further reason for clinicians to pay attention to alexithymic features among their patients.