“Stigma surrounding mental illness often prevents patients from seeking the mental health care they need, delaying care and prolonging suffering. Fear, embarrassment, and impaired quality of life are a reality for many patients suffering from skin disorders like severe cases of psoriasis, hair loss, or acne. In these cases, assistance from a dermatologist who bridges both specialties might be better accepted by patients and can help them find relief for their skin and mind more quickly.

When it comes to helping the millions of Americans suffering from skin issues, whether a flare-up or the management of a chronic condition, exploring both the physical and emotional causes of disease is key to a successful treatment. Neglecting how our emotional lives affect the largest organ of the human body is a mistake, and thankfully, psychodermatological treatments are now available to complement conventional therapies.”

Katlein França is a dermatologist.

She shares her story and discusses her KevinMD article, “Want your skin to look better? Then consider your mental health.”

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Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Rate and review the show at KevinMD.com/rate. Subscribe at KevinMD.com/follow. Today’s show is with Katlein França. She is a dermatologist. She wrote the KevinMD article “Want your skin to look better? Then consider your mental health.” Katlein, welcome to the show.

Katlein França: Thank you so much, Kevin, for having me here.

Kevin Pho: We’ll get into your article in a little bit. First off, just briefly share your story and journey to where you are today.

Katlein França: Absolutely. I’m a dermatologist, and I specialize in psychodermatology. I am an assistant professor at the Department of Dermatology and Cutaneous Surgery, and also Psychiatry and Behavioral Sciences, of the University of Miami Miller School of Medicine. I’m currently the director of the Psychoneurocutaneous Medicine Center of the same university.

Kevin Pho: I have to admit, I don’t know too much about psychodermatology. Tell my audience a little bit about what that is.

Katlein França: Well, this is an emerging subspecialty of medicine that combines the fields of dermatology, psychiatry, and psychology, and it is here to offer traditional treatments, but also complementary treatments with scientific evidence, for patients suffering from skin diseases.

Kevin Pho: All right. So walk us through a typical day in your exam room. Tell us an example of some of the cases you might see as a psychodermatologist.

Katlein França: Well, there are many skin conditions, for example, psoriasis, vitiligo, or acne, that can impact the mental health of anybody suffering from those diseases. So in the daily life of a dermatologist, we see many of these common skin disorders, and many patients who are psychologically impacted by them.

We also have other psychiatric disorders that can have manifestations in the skin. For example, we’re talking about obsessive-compulsive disorders and the spectrum, such as skin picking, trichotillomania, where the person pulls the hair out, or nail biting. And other diseases, like delusional diseases, can manifest in the skin. For example, there are patients who have what we call delusions of parasitosis, who might have this false belief that their skin is infested or infected by parasites.

Kevin Pho: Now, what kind of training do you need to become a psychodermatologist? Do you become a dermatologist first and then do a psychiatry residency? What’s the training involved to become a psychodermatologist?

Katlein França: There is no official program in the United States. There are a couple of certifications available now in Europe, but there’s no official fellowship training program to train psychodermatologists. So we have a few persons practicing in the United States, and basically we have different backgrounds.

I am a dermatologist, for example, and then I did a PhD in psychology. And obviously I have this interest in the field, so I’ve been performing research and teaching and participating in many meetings, nationally and internationally, so I can always update myself. But we do have colleagues in the United States who are dermatologists who then did the psychiatry residency, or who were psychiatrists before and then did additional training in dermatology.

Kevin Pho: Now, you mentioned something like psoriasis as a typical case that you would see. So take us into your exam room from the lens of a psychodermatologist. What kind of issues will come up, and then how would you approach a patient like that?

Katlein França: Well, psoriasis is a chronic condition of the skin, and gladly, we have many treatments available nowadays that can help the person to improve the skin. However, you see that this disease often causes mental health issues. These patients often suffer from anxiety, depression, and stigma. Some people might have this false belief that the disease is contagious. We have many patients like that, more particularly with these more extensive cases of psoriasis.

So we need to address the mental health problem. Very often these patients need additional psychotherapy, and sometimes antidepressant medications, which are going to help them throughout the dermatological treatment. Obviously we’re going to be providing them the mainstream treatments with medications, but we need to address the mental health issue.

Kevin Pho: All right. And you talk more about that in your KevinMD article. It’s titled “Want your skin to look better? Then consider your mental health.” Now, for those who didn’t get a chance to read your article, just walk my audience through it and share the story of why you decided to write it.

Katlein França: Very good, thank you so much. That’s a great question. The article “Want your skin to look better? Then consider your mental health.” was written with the goal of increasing awareness of the field of psychodermatology. The goal was basically to make the public and other physicians aware of the existence of this emerging field that, as I said before, combines dermatology, psychiatry, and psychology, and also of how patients can benefit from having a consultation with a psychodermatologist.

Over the last two decades, numerous studies have linked emotional stress, depression, and anxiety to many dermatological conditions. We know that repeated exposure to psychological or environmental stressors can have long-lasting effects on the skin. Also, stress can release hormones such as cortisol and adrenaline into the body, which can cause inflammation, make the skin more reactive, and lead to different skin diseases.

Kevin Pho: Now, you mentioned that this is an emerging field in the United States. Just give us a sense of how one can go about finding a psychodermatologist.

Katlein França: Well, nowadays there is an association called the Association for Psychoneurocutaneous Medicine of North America. On their website, they can guide you, and you can find some local professionals who are practicing psychodermatologists. Then you can also reach out to your community to see if there’s any psychodermatologist available. Usually, dermatologists’ offices are able to guide you, or if they don’t practice psychodermatology officially, most likely they will be able to refer you to a psychologist or a psychiatrist who can work in conjunction.

Kevin Pho: Normally, there’s a stereotype about dermatologists that they’re able to see a lot of patients during the day, and their office visit times are a little bit on the shorter side. That’s the stereotype that a lot of dermatologists have. How much time do you spend with each patient during the day?

Katlein França: That’s correct. Since we have this dedicated space, which is the Psychoneurocutaneous Medicine Center, I am allowed to have 30 minutes, sometimes 45 minutes, with the patients as needed. I know that’s not what happens in the daily life of dermatologists, but this is what we psychodermatologists ask for, because this is the time we require with each patient, and sometimes it’s not even enough to address all the concerns. So in our office, we have that privilege of having more time.

Kevin Pho: Now, I’m going to put you on the spot here and ask you to tell me a case study, a story, a success story. It could be a hypothetical patient, but I really want to paint a picture of psychodermatology. Tell me a success story of a patient who came in to see you, what you did, and how you helped them.

Katlein França: Well, I think many psychodermatologists encounter cases of patients believing that they have parasitic infections in the skin. Some of them have seen many other providers before, and there is no real parasitic infection when you examine the patient. That’s a disease called delusions of parasitosis, or pseudoparasitic dysesthesia. I haven’t seen many patients with that condition, and I think you need to first have a very good doctor-patient relationship, so the patient likes you and you can guide the patient through the process of that disease.

Once you see the patient, you exclude causes for that, like physical causes such as medications, or other conditions, other neurological conditions that could be triggering those symptoms. If you don’t find any of that in the screening that you perform with the patient, we often tend to prescribe these patients low doses of antipsychotic medications, and that can help their nervous system. These delusions usually go away with a low dose of antipsychotic medication.

So I had treated a couple of patients and followed them through this journey, and it’s very nice to see how much they improve, some of them in a short period of time, once you give them the right medications. And there are other patients where we could find a physical cause for their problem, and once that was treated or addressed, those sensations of parasitic infection just went away.

Kevin Pho: We’re talking to Katlein França. She’s a dermatologist. She wrote the KevinMD article “Want your skin to look better? Then consider your mental health.”

I’m a primary care physician. I do internal medicine, and I don’t quite have half an hour with each patient, but I have 15 minutes, and typically I do get patients with an initial presentation of whatever skin condition. Now, through your lens, what kind of questions could I ask them in the exam room that could perhaps uncover a psychological ramification of their skin condition?

Katlein França: I think you just start with basic questions: How do you feel? Is this impacting your life? How’s your sleep? How’s your quality of life? Are you exercising? Do you have pleasure in your daily life? I think just those basic questions can give you an idea of how much that skin disorder can be impacting that person’s life.

Kevin Pho: Now, what are some sample answers that you typically get when you do ask patients these questions?

Katlein França: Some of them say, “Oh, no, I don’t want to leave my home because my skin, my face is disfigured,” or, “I have these lesions all over my body,” or, “I am extremely itchy. I cannot sleep during the night. I don’t want to exercise,” or, “I don’t want other people to see me.” So in those cases, those are like red lights. You need to pay attention to those patients and say, “Hey, the skin condition is really impacting this patient’s mental health, and it’s time for us to address this and do something about it.”

Kevin Pho: And my final question, what are some of your take-home messages that you want to leave with the KevinMD audience?

Katlein França: I think we have millions of Americans suffering from skin diseases, so exploring the physical and emotional causes of diseases is the key to a successful treatment. We cannot neglect how our emotional lives can affect the largest organ of the human body. And the field of psychodermatology is available to provide these conventional and complementary therapies with scientific evidence that will help you improve your skin health and beauty.

Kevin Pho: Well, thank you so much for educating us about this field and sharing your time and insight.

Katlein França: Thank you so much for having me today.