Next Steps readers had the opportunity to ask internationally recognized clinician and researcher, Dr. Richard Fried questions about the psychological impact of psoriasis and how to better serve psoriasis patients. See all his insightful answers below.
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When it comes to depression, in what ways does psoriasis affect women more profoundly than men?
My initial response is that we cannot “automatically assume” that the psychological impact of psoriasis is greater in women than it is in men. However, given the enormous pressure that women endure demanding perfection in skin and body appearance, that emotional groundwork is in place for greater psychological impact including depression, anxiety, and body dysmorphic disorder.
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What can dermatologists do to address the specific concerns of women with psoriasis?
Initially, offering genuine and empathic statements that show caring and sensitivity. With appropriately sustained eye contact, clinicians should express their understanding that it can be extremely difficult to live with a visible and physically uncomfortable skin disease. Perhaps suggesting that the societal focus on skin perfection is particularly burdensome for women.
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Many of my psoriasis patients who have come to see me for a second opinion have been told by their former derm that they should “learn to live with it”. What can we do to eradicate this way of thinking?
Ask them politely to leave clinical practice (only kidding). Such dismissive statements underestimate the psychosocial impact of the disease and leave sufferers adrift without an appropriate, mutually agreeable treatment program. This situation sheds light on the difficult decisions regarding thresholds of treatment. Clinicians should be aware that sometimes patients are at a critical (breaking point) and thus moving to a more efficacious therapy may be essential for both quality of life and continuation of life. We must never underestimate the psychosocial and functional impairment of a capricious disease like psoriasis. PASI scores may or may not be reflective of psychosocial impact.
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Can you please share any concrete strategies that we, as dermatologists, can implement with our patients to show support and empathy for how psoriasis affects their phycological health? I want to be seen as more than a guy prescribing a medication…I want my patients to know I feel their pain. How do we do that without becoming their “therapist”?
Patients and puppies can sense kindness and caring. Looking beyond the EMR program in front of you, look nonjudgmentally and directly at the patient and subjectively ask yourself how difficult it would be to live with their skin disease. Very briefly share with them the existing data on comorbidities such as anxiety, depression, social withdrawal, vocational impairment, sexual impairment, etc. Stating simply that you are always concerned about how skin disease affects your patients conveys an attitude of caring and acceptance. Having available recommendations for colleagues that can be referred to as “skin-emotion specialists” such as psychologists, psychiatrists, and other mental health and complementary practitioners can be extremely helpful. Destigmatizing engagement with mental health professionals can be extremely helpful and can empower patients to learn techniques to improve coping skills and decrease negative psychophysiologic reactivity.
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Sex is rarely talked about during consults with my psoriasis patients despite the clear relationship between the two. How do you approach the subject with your patients?
I find that it is helpful to speak to patients about how psoriasis can be a “thief” that can steal from us many of our pleasurable activities and effective relationships with significant others. While I usually do not directly bring up the topic of sexuality, I do make broad statements that effective psoriasis treatments can be liberating allowing us to engage or reengage in our full range of pleasurable activities. Interestingly, I once heard it said that there is a difference between whether a person misses sexual intimacy versus concretely, how much sex and intimacy do they miss. In other words, the loss of desire may be hidden “beneath the plaques” and in the psyche. Consequently, there is a loss of intimacy which further exacerbates the psychosocial impact.
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When it comes to discussing the impact of psoriasis in your patients’ sexual life, do you see any remarkable differences in the questions/concerns that female vs. male patients bring up?
No, both are usually equally non-forthcoming. Occasionally, patients, male or female, or very vocal regarding their concerns, embarrassment, and frustrations regarding the impact on sexuality. What seems to be the best approach is conveying a sense of caring and a nonjudgmental posture allowing for open conversation.
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Do you think dermatologists under prescribe biologics for psoriasis? If so, why?
Yes, I do think some dermatologists under prescribe biologics for psoriasis. I believe for some clinicians it is analogous to isotretinoin where patient concerns about safety and potential negative emotional impact make them less likely to prescribe. As we know, and it has been clearly shown that isotretinoin is a remarkably safe medication that lessens depression and improves functional status. The biologic agent for psoriasis appears to function similarly with the diminution in systemic inflammation and improvement in emotional and functional status.
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Is there anything that us, as dermatologists, should never tell a psoriasis patient?
Yes, we should never tell a patient or implied to a patient that we have run out of options. There should always be a clear message that we have a large “tool bag” of effective therapies that will control their psoriasis and allow them to return to an actively engaged life. I believe one of the huge fears that psoriasis sufferers live with is that their disease will progress and persists throughout their lifetime.
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Do you often refer your psoriasis patients to a therapist? What are some visible signs that may trigger you to do so?
I do sometimes refer patients for psychologic intervention. I have a euphemism for mental health professionals in dermatology that seems to diminish much of the negative connotation that can be associated with a recommendation to a mental health professional. We call our aligned specialists “skin emotion specialists”. Most of them are psychologists or psychiatrists who mainly employ cognitive-behavioral psychotherapy and appropriate cycle pharmacologic agents.
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I have always been very interested in the field of Psychodermatology but it is rarely talked about at dermatology conferences/meetings and many of my colleagues are very skeptical about it. Why do you think that is?
Largely, because you can’t see it, touch it, magnify it, biopsy it, ablate it, or excise it. Many perceive psychodermatology as a “less scientific” area and a potential black hole that can be time-consuming and emotionally difficult. I challenge our colleagues who believe or state that they do not practice psychodermatology. Every smile, gentle touch, empathic statement, optimistic statement, and a prescription for diphenhydramine, doxepin, isotretinoin, and biologics all can be considered psychodermatology. For those skeptical of a rapid and observable mind-body connection, we need to look no further than a blush/flush reaction. A simple cognition that one said or did something foolish elicits an almost instantaneous derangement of the cutaneous vasculature. The exacerbation of the blush/flush of rosacea or the hyperhidrotic axillae caused by embarrassment and anxiety are further day-to-day examples.
What clinicians need are concise, short, and effective techniques to enhance patient trust, adherence to treatments, and satisfaction with their clinician and treatment. Psychodermatologic techniques can be invaluable in achieving short and long-term clinical benefit.
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What’s one book you think all derms should read (no textbooks!)?
The healing power of mindfulness: A new way of being – Jon Kabat-Zinn
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