Skin and wound care involves treating the whole person who is wounded, as well as the components of local wound care. Included in the Wound Bed Preparation model, patient-centered concerns are the subject of several articles in this month’s issue.
The original conceptual psychocutaneous disease framework developed by dermatologist-psychoanalyst Dr Caroline Koblenzer1 was further refined by Drs John Koo and Lebwohl2 with three distinct categories:
- Psychophysiologic disorders (eg, psoriasis and eczema) associated with skin problems not directly connected to the mind but affected by emotional states
- Primary psychiatric disorders with self-induced cutaneous manifestations (eg, dermatitis artefacta, trichotillomania)
- Secondary psychiatric disorders associated with disfiguring or painful skin disorders (eg, scars)
In this issue of Advances, Dr Meghan McPhie and colleagues identify three pyoderma gangrenosum (PG) studies that examined 183 patients for depression. The patients were all from North America with an overall depression rate of 18.4%, compared with a reported US 12-month rate of 6% to 7% and a Canadian rate of 4.7%. The authors postulated that this may be attributable to the psychological stress of the pain and lengthy healing, with only 50% of the patients clear of lesions after a year. The authors also postulated that the proinflammatory cytokines associated with PG lesions may increase these patients’ susceptibility to depression. In fact, PG is no longer a diagnosis of exclusion but rather requires biopsy confirmation of neutrophilic predominant dermatoses infiltrates.3
These findings bring to mind another recent article in which Guo and colleagues4 evaluated life quality, anxiety, and depression in 1,127 patients with skin disease. The authors identified psoriasis, atopic dermatitis, acne, steroid-dependent dermatitis, and alopecia to have a negative impact on life quality in most patients, along with associated anxiety and depression.
In 2008, Dr Koblenzer stated that “youth culture fits in here… with the attendant depreciation of the value and the beauty of aging.”5 Fragile skin may occur with aging, and the Practice Reflections article in this issue written by Dr Diane Langemo and colleagues reflects on the vulnerability of the skin and how the frailty syndrome from geriatrics can be applied to the prevention and management of common clinical skin and wound problems. They stress the importance of considering the work of Rockwood and Mitnitski6 insofar as frailty syndrome is a “concomitant interplay of physical, psychological, social, environmental, and economic factors such as aging, sun exposure, and/or genetics.” Aging and fragile skin may be susceptible to damage and associated with depression along with falls, fractures, type 2 diabetes, poor nutrition, coronary heart disease, and arthritis. This column discusses elements of appropriate skin care and practice change processes for everyday clinical practice to enhance whole-patient care.
Treating depression goes well beyond medication. This month’s continuing education article outlines the need to explore the patient’s perspective to increase treatment adherence. The authors distinguish between adherence and compliance; the latter demands the patient conform to the healthcare practitioner’s directives. As stated in the article, adherence is “the extent to which a person’s behavior—taking medication, following a diet, and/or executing lifestyle changes—corresponds with agreed recommendations from the healthcare provider.” The article provides an example of a motivational interview using four theoretical models. Patients need to be ready to change, with the action taking 0 to 6 months, and maintain that change for 6 months or longer. A motivational interview with open-ended questions can take 30 to 60 minutes, but a brief single goal session could be as short as 5 to 10 minutes—time well spent to enhance healing and reduce the psychological burden of wounds.
It is time to consider clinicians with expertise in mental health as members of the interprofessional skin and wound care team to help address psychological issues including depression. Are you up for the challenge to improve patient adherence and tackle patient-centered care, including the psychophysiological aspects of skin and wound care?
R. Gary Sibbald, MD, DSc(Hons), MEd, BSc, FRCPC(Med Derm), FAAD, MAPWCA, JM
Elizabeth A. Ayello, PhD, MS, BSN, RN, CWON, ETN, MAPWCA, FAAN
1. Koblenzer CS. Psychosomatic concepts in dermatology. A dermatologist-psychoanalyst’s viewpoint. Arch Dermatol 1983;119(6):501–12.
2. Koo J, Lebwohl A. Pschodermatology: the mind skin connection. Am Fam Physician 2001;64:1873–78.
3. Maverakis E, Ma C, Shinkai K, et al. Diagnostic criteria of ulcerative pyoderma gangrenosum? A Delphi consensus of international experts. JAMA Dermatol 2018;154:461–6.
4. Guo F, Yu Q, Liu Z, et al. Evaluation of life quality, anxiety, and depression in patients with skin diseases. Medicine 2020;99:44(e22983).
5. Barankin B. SPOTLIGHT on Caroline Koblenzer, MD. Dermatology Learning Network. December 2008. www.hmpgloballearningnetwork.com/site/thederm/site/cathlab/event/spotlight-caroline-koblenzer-md
. Last accessed June 21, 2021.
6. Rockwood K, Mitnitski A. Frailty in relation to the accumulation of deficits. J Gerontol A Biol Sci Med 2007;(7):722–7.